Basic Information
| Provider Information | |||||||||
| NPI: | 1003051020 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAZADERM SKIN CARE CENTRE PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5126 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053351952 | ||||||||
| FaxNumber: | 6053739971 | ||||||||
| Practice Location | |||||||||
| Address1: | 5011 S LOUISE AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571082268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052756128 | ||||||||
| FaxNumber: | 6053739971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2008 | ||||||||
| LastUpdateDate: | 12/29/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | LORNELL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER AND OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6052756128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | DO9926 | 01 | SD | RAILROAD MEDICARE | OTHER |