1760418008 NPI number — ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD

Table of content: (NPI 1760418008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760418008 NPI number — ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD
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:
1760418008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2224 W NORTHERN AVE
Provider Second Line Business Mailing Address:
D 300
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85021-4928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-277-1449
Provider Business Mailing Address Fax Number:
602-277-9984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 E BASELINE RD
Provider Second Line Business Practice Location Address:
SUITE B-8
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85234-2726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-844-0510
Provider Business Practice Location Address Fax Number:
480-844-1663
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SUPERFON
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
602-277-1449

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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