Healthcare Provider Details

I. General information

NPI: 1902355720
Provider Name (Legal Business Name): ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 N CENTRAL AVE
COOLIDGE AZ
85128-4405
US

IV. Provider business mailing address

2224 W NORTHERN AVE SUITE D300
PHOENIX AZ
85021-4928
US

V. Phone/Fax

Practice location:
  • Phone: 520-723-8182
  • Fax: 520-723-9172
Mailing address:
  • Phone: 602-277-1449
  • Fax: 602-277-9984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: NEIL P SUPERFON
Title or Position: PHYSICIAN/OWNER
Credential: DO
Phone: 602-277-2247