Healthcare Provider Details

I. General information

NPI: 1003209248
Provider Name (Legal Business Name): AZEAL DERMATOLOGY INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5365 SPINE RD SUITE C
BOULDER CO
80301-3324
US

IV. Provider business mailing address

PO BOX 7446
LOVELAND CO
80537-0446
US

V. Phone/Fax

Practice location:
  • Phone: 303-530-9325
  • Fax:
Mailing address:
  • Phone: 970-663-2742
  • Fax: 970-667-0847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: STACEY PILKINGTON
Title or Position: OWNER
Credential: D.O.
Phone: 303-530-9325