Healthcare Provider Details

I. General information

NPI: 1568033066
Provider Name (Legal Business Name): INTEGRATED DERMATOLOGY OF BOULDER CREEK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S MCCASLIN BLVD STE 100
SUPERIOR CO
80027-9701
US

IV. Provider business mailing address

4700 EXCHANGE CT STE 110
BOCA RATON FL
33431-4450
US

V. Phone/Fax

Practice location:
  • Phone: 303-666-5261
  • Fax: 303-604-6062
Mailing address:
  • Phone: 561-431-2821
  • Fax:

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 Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DAVID FUENTES
Title or Position: AUTHORIZED
Credential:
Phone: 561-314-2000