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General NPI Number Information
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NPI Number | 1013667161
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Entity Type | Organization
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Legal Business Name | CLEAR CREEK DERMATOLOGY
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Dates
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Enumeration Date | 03/23/2022
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Last Update Date | 09/13/2023
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Provider Practice Location Address
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Address Line | 904 FORD ST
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City | LLANO
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State | TX
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Zip | 78643-2345
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Country | US
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Telephone | 830-953-1700
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Fax | 830-953-1717
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Provider Business Mailing Address
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Address Line | 904 FORD ST
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City | LLANO
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State | TX
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Zip | 78643-2345
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Country | US
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Telephone | 830-953-1700
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Fax | 830-953-1717
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Authorized Official
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Title or Position | OWNER
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Name | EMILY LIGA PROSISE
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Credential | MD
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Telephone | 830-953-1700
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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 |
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License Number State |
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