Healthcare Provider Details

I. General information

NPI: 1124386966
Provider Name (Legal Business Name): SOUTHWEST SKIN LABORATORY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1684 E BOSTON ST STE 105
GILBERT AZ
85295-6219
US

IV. Provider business mailing address

1688 E BOSTON ST STE 101
GILBERT AZ
85295-6222
US

V. Phone/Fax

Practice location:
  • Phone: 480-855-0085
  • Fax: 480-855-0086
Mailing address:
  • Phone: 480-855-0085
  • Fax: 480-855-0086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number03D2046062
License Number StateAZ

VIII. Authorized Official

Name: DR. MATTHEW TRAVIS WOODS
Title or Position: OWNER
Credential: MD
Phone: 480-855-0085