Healthcare Provider Details

I. General information

NPI: 1518683242
Provider Name (Legal Business Name): SKIN N BONES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4961 ROYAL GULF CIR
FORT MYERS FL
33966-7006
US

IV. Provider business mailing address

4961 ROYAL GULF CIR
FORT MYERS FL
33966-7006
US

V. Phone/Fax

Practice location:
  • Phone: 239-687-4015
  • Fax: 321-421-0393
Mailing address:
  • Phone: 239-687-4015
  • Fax: 321-421-0393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JARED REISS
Title or Position: OWNER
Credential: PA
Phone: 239-687-4015