Healthcare Provider Details

I. General information

NPI: 1407992373
Provider Name (Legal Business Name): MY SKIN CLINICS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 04/09/2022
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 HIGHWAY 71 UNIT 1&4
SPIRIT LAKE IA
51360-7634
US

IV. Provider business mailing address

PO BOX 125
OKOBOJI IA
51355-0125
US

V. Phone/Fax

Practice location:
  • Phone: 712-332-6001
  • Fax: 712-332-6010
Mailing address:
  • Phone: 712-332-6001
  • Fax: 712-332-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number24582
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number24582
License Number StateIA

VIII. Authorized Official

Name: RONALD J KOLEGRAFF
Title or Position: OWNER AND PROVIDER
Credential: MD
Phone: 712-332-6001