Basic Information
| Provider Information | |||||||||
| NPI: | 1275998692 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SKINSPA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SKINGYM BY ASHLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9350 UNIVERSITY AVE STE 132 | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502661648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 9350 UNIVERSITY AVE STE 132 | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502661648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018702780 | ||||||||
| FaxNumber: | 5152880122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2015 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | VAN ZETTEN | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8018702780 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD-42639 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.