Healthcare Provider Details

I. General information

NPI: 1689991937
Provider Name (Legal Business Name): SKIN CARE NOW PUEBLO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N GRAND AVE
PUEBLO CO
81003-3111
US

IV. Provider business mailing address

415 N GRAND AVE
PUEBLO CO
81003-3111
US

V. Phone/Fax

Practice location:
  • Phone: 719-924-8448
  • Fax: 719-546-3334
Mailing address:
  • Phone: 719-924-8448
  • Fax: 719-546-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD B LANE
Title or Position: C.E.O.
Credential:
Phone: 719-406-9304