Basic Information
| Provider Information | |||||||||
| NPI: | 1629175617 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ZEL SKIN & LASER SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 W 50TH ST | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554241200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529298888 | ||||||||
| FaxNumber: | 9529299669 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 W 50TH ST | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554241200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529298888 | ||||||||
| FaxNumber: | 9529299669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 06/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9527461018 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | HFID24276 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.