Healthcare Provider Details

I. General information

NPI: 1528216314
Provider Name (Legal Business Name): ACACIA DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 03/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 N LOCUST AVE SUITE D
LAWRENCEBURG TN
38464-4455
US

IV. Provider business mailing address

2131 N LOCUST AVE SUITE D
LAWRENCEBURG TN
38464-4455
US

V. Phone/Fax

Practice location:
  • Phone: 931-762-6545
  • Fax: 931-762-6781
Mailing address:
  • Phone: 931-762-6545
  • Fax: 931-762-6781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number43761
License Number StateTN

VIII. Authorized Official

Name: ROBERT L CHEN
Title or Position: OWNER
Credential: MD
Phone: 931-762-6545