Healthcare Provider Details

I. General information

NPI: 1497270664
Provider Name (Legal Business Name): SKIN CONCIERGE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W. ST. MARY'S ROAD 2ND FLOOR, SUITE A
TUCSON AZ
85745
US

IV. Provider business mailing address

1310 W SAINT MARYS RD STE A
TUCSON AZ
85745-3231
US

V. Phone/Fax

Practice location:
  • Phone: 520-333-5973
  • Fax: 520-221-2318
Mailing address:
  • Phone: 520-333-5973
  • Fax: 520-221-2318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: DESTINY GYPSYLEE MATTOX
Title or Position: PRACTICE MANAGER
Credential:
Phone: 520-333-5973