Healthcare Provider Details

I. General information

NPI: 1477169753
Provider Name (Legal Business Name): HEARTHSTONE DERMATOLOGY NONPROFIT PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 MOX CHEHALIS RD
MCCLEARY WA
98557-9408
US

IV. Provider business mailing address

828 MOX CHEHALIS RD
MCCLEARY WA
98557-9408
US

V. Phone/Fax

Practice location:
  • Phone: 360-470-0671
  • Fax: 360-464-2617
Mailing address:
  • Phone: 360-470-0671
  • Fax: 360-464-2617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: GENEVA TZENOV
Title or Position: CEO-ADMINISTRATOR
Credential: FNP-C
Phone: 360-470-0671