1871995324 NPI number — SKIN CANCER & COSMETIC DERMATOLOGY CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871995324 NPI number — SKIN CANCER & COSMETIC DERMATOLOGY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKIN CANCER & COSMETIC DERMATOLOGY CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871995324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7070 E DRIVE NORTH
Provider Second Line Business Mailing Address:
C/O DSSC
Provider Business Mailing Address City Name:
BATTLE CREEK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-660-1670
Provider Business Mailing Address Fax Number:
269-660-0666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 E MAUMEE ST
Provider Second Line Business Practice Location Address:
SUITE 301 - CAMERON MEDICAL OFFICE BUILDING
Provider Business Practice Location Address City Name:
ANGOLA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46703-2038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-660-1670
Provider Business Practice Location Address Fax Number:
269-660-0666
Provider Enumeration Date:
09/16/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LATOUR
Authorized Official First Name:
DONN
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
26966016710

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  01074279A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)