Healthcare Provider Details

I. General information

NPI: 1982308508
Provider Name (Legal Business Name): REFORME DERMATOLOGY AND AESTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 WINGO WAY STE 303
MOUNT PLEASANT SC
29464-2839
US

IV. Provider business mailing address

2265 TILLAGE ST
MOUNT PLEASANT SC
29466-9505
US

V. Phone/Fax

Practice location:
  • Phone: 843-974-1230
  • Fax: 843-974-1231
Mailing address:
  • Phone: 302-893-2411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GABRIELLA VASILE
Title or Position: OWNER
Credential: DO
Phone: 302-893-2411