=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013197961
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY OF THE SUN SURGICAL DERMATOLOGY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2007
-----------------------------------------------------
Last Update Date | 09/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8406 E SHEA BLVD SUITE 100
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-6659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-998-1158
-----------------------------------------------------
Fax | 480-998-0123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8406 E SHEA BLVD STE 100
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-6659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-998-1158
-----------------------------------------------------
Fax | 480-998-0123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. LORA J PLATTNER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 480-998-1158
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 24109
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------