Healthcare Provider Details

I. General information

NPI: 1063715423
Provider Name (Legal Business Name): SKIN CANCER AND COSMETIC DERMATOLOGY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 01/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 DIXIE LEE CENTER RD SUITE C
KIMBALL TN
37347-5672
US

IV. Provider business mailing address

1107 MEMORIAL DR SUITE 201
DALTON GA
30720-8668
US

V. Phone/Fax

Practice location:
  • Phone: 706-277-7311
  • Fax: 706-272-3512
Mailing address:
  • Phone: 706-277-7311
  • Fax: 706-272-3512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLEY FINNELL
Title or Position: PRACTICE MANAGER
Credential:
Phone: 706-277-7311