Healthcare Provider Details

I. General information

NPI: 1407215817
Provider Name (Legal Business Name): SKIN CENTER OF GEORGIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 JESSE JEWELL PKWY SE SUITE 500
GAINESVILLE GA
30501-3871
US

IV. Provider business mailing address

PO BOX 1456
GAINESVILLE GA
30503-1456
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-7546
  • Fax: 770-535-7591
Mailing address:
  • Phone: 770-535-7546
  • Fax: 770-535-7591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number058402
License Number StateGA

VIII. Authorized Official

Name: DR. MISTY CAUDELL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 706-201-6324