MEDICARE: EXQUISITE DERMATOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	ME109349	DE

General Provider Information

NPI Number	:	1053779223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXQUISITE DERMATOLOGY LLC

Provider Business Mailing Address
First Line	:	12315 LAKE UNDERHILL RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-4507
Country	:	US
Telephone Number	:	407-403-5620
Fax Number	:	407-412-5920

Provider Business Practice Location Address
First Line	:	12315 LAKE UNDERHILL RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-4507
Country	:	US
Telephone Number	:	407-403-5620
Fax Number	:	407-412-5920

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. LOUISE M CLINGMAN
Credential	:
Telephone Number	:	407-459-5213

Provider Enumeration Date	:	02/03/2016
Last Update Date	:	05/04/2016

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