Basic Information
| Provider Information | |||||||||
| NPI: | 1346420577 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY CENTER OF YUMA PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2270 S RIDGEVIEW DR | ||||||||
| Address2: | STE 302 | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287830169 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2270 S RIDGEVIEW DR | ||||||||
| Address2: | STE 302 | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287830169 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2007 | ||||||||
| LastUpdateDate: | 03/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | LUCHETTI | ||||||||
| AuthorizedOfficialFirstName: | MARY ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | JOAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9283294761 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DERMATOLOGY CENTER OF YUMA PLLC | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 044009 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | 28963 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.