Healthcare Provider Details

I. General information

NPI: 1700933744
Provider Name (Legal Business Name): DERMATHERIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 E MAIN ST
RICHMOND IN
47374-4331
US

IV. Provider business mailing address

748 NORTHSIDE CT
CONNERSVILLE IN
47331-2583
US

V. Phone/Fax

Practice location:
  • Phone: 765-965-7546
  • Fax:
Mailing address:
  • Phone: 765-827-4000
  • Fax: 765-827-4000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES J HUBER JR.
Title or Position: OWNER
Credential:
Phone: 765-827-4000