1912912361 NPI number — PREMIER DERMATOLOGY & SKIN RENEWAL CENTER

Table of content: (NPI 1912912361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912912361 NPI number — PREMIER DERMATOLOGY & SKIN RENEWAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER DERMATOLOGY & SKIN RENEWAL 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:
1912912361
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 SE 28TH ST
Provider Second Line Business Mailing Address:
STE 5
Provider Business Mailing Address City Name:
BENTONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72712-3880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-273-3376
Provider Business Mailing Address Fax Number:
479-273-3468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 SE 28TH ST
Provider Second Line Business Practice Location Address:
STE 5
Provider Business Practice Location Address City Name:
BENTONVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72712-3880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-273-3376
Provider Business Practice Location Address Fax Number:
479-273-3468
Provider Enumeration Date:
07/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CLIFTON
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
479-273-3376

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  E3363 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207NP0225X , with the licence number: E3363 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207NS0135X , with the licence number: E3363 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207NI0002X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 1679521405 . This is a "NPI - MILDRED CLIFTON, MD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 03060015000 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".