Basic Information
| Provider Information | |||||||||
| NPI: | 1659829109 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2224 W NORTHERN AVE | ||||||||
| Address2: | SUITE D300 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850214928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022771449 | ||||||||
| FaxNumber: | 6022779984 | ||||||||
| Practice Location | |||||||||
| Address1: | 6644 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808440510 | ||||||||
| FaxNumber: | 6022779984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2016 | ||||||||
| LastUpdateDate: | 09/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | SUPERFON | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6022772247 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.