Healthcare Provider Details

I. General information

NPI: 1952724213
Provider Name (Legal Business Name): BEYOUTIFUL SKIN AND LASER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4066 HIXSON PIKE
CHATTANOOGA TN
37415-3110
US

IV. Provider business mailing address

4066 HIXSON PIKE
CHATTANOOGA TN
37415-3110
US

V. Phone/Fax

Practice location:
  • Phone: 423-877-3568
  • Fax: 423-877-9332
Mailing address:
  • Phone: 423-877-3568
  • Fax: 423-877-9332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA0000000981
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8749977
License Number StateTN

VIII. Authorized Official

Name: MR. EDDIE D JENKINS
Title or Position: GM
Credential:
Phone: 423-877-3568