Healthcare Provider Details

I. General information

NPI: 1467051409
Provider Name (Legal Business Name): GGSKINLASERHAIR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 SANGAMORE RD STE S207
BETHESDA MD
20816-2529
US

IV. Provider business mailing address

4701 SANGAMORE RD STE S207
BETHESDA MD
20816-2529
US

V. Phone/Fax

Practice location:
  • Phone: 202-684-7167
  • Fax: 240-483-0441
Mailing address:
  • Phone: 202-684-7167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELLY GOODMAN
Title or Position: NURSE PRACTIONER / OWNER
Credential: NP
Phone: 202-684-7167