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General NPI Number Information
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NPI Number | 1003350760
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Entity Type | Organization
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Legal Business Name | WARTHAN DERMATOLOGY CENTER
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Dates
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Enumeration Date | 12/14/2016
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Last Update Date | 12/14/2016
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Provider Practice Location Address
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Address Line | 4730 NE STALLINGS DR
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City | NACOGDOCHES
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State | TX
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Zip | 75965-1615
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Country | US
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Telephone | 936-564-6107
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Fax | 936-564-5124
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Provider Business Mailing Address
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Address Line | 4730 NE STALLINGS DR
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City | NACOGDOCHES
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State | TX
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Zip | 75965-1615
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Country | US
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Telephone | 936-564-6107
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Fax | 936-564-5124
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Authorized Official
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Title or Position | BILLING
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Name | JACLYN R HILL
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Credential |
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Telephone | 817-923-8220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | D8472
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License Number State | TX
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