Healthcare Provider Details

I. General information

NPI: 1760418008
Provider Name (Legal Business Name): ARIZONA SKIN AND LASER THERAPY INSTITUTE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 E BASELINE RD SUITE B-8
GILBERT AZ
85234-2726
US

IV. Provider business mailing address

2224 W NORTHERN AVE D 300
PHOENIX AZ
85021-4928
US

V. Phone/Fax

Practice location:
  • Phone: 480-844-0510
  • Fax: 480-844-1663
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: OWNER/PHYSICIAN
Credential: D.O.
Phone: 602-277-1449