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General NPI Number Information
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NPI Number | 1053779223
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Entity Type | Organization
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Legal Business Name | EXQUISITE DERMATOLOGY LLC
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Dates
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Enumeration Date | 02/03/2016
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Last Update Date | 05/04/2016
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Provider Practice Location Address
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Address Line | 12315 LAKE UNDERHILL RD
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City | ORLANDO
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State | FL
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Zip | 32828-4507
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Country | US
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Telephone | 407-403-5620
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Fax | 407-412-5920
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Provider Business Mailing Address
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Address Line | 12315 LAKE UNDERHILL RD
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City | ORLANDO
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State | FL
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Zip | 32828-4507
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Country | US
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Telephone | 407-403-5620
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Fax | 407-412-5920
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. LOUISE M CLINGMAN
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Credential |
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Telephone | 407-459-5213
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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 | ME109349
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License Number State | DE
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