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General NPI Number Information
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NPI Number | 1154735819
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Entity Type | Organization
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Legal Business Name | ELITE DERMATOLOGY AND AESTHETIC INSTITUTE, LLC
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Dates
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Enumeration Date | 06/20/2014
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Last Update Date | 11/19/2015
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Provider Practice Location Address
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Address Line | 1905 CLINT MOORE RD SUITE 203
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City | BOCA RATON
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State | FL
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Zip | 33496-2658
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Country | US
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Telephone | 561-826-6650
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Fax | 561-826-6649
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Provider Business Mailing Address
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Address Line | 1905 CLINT MOORE RD SUITE 203
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City | BOCA RATON
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State | FL
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Zip | 33496-2658
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Country | US
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Telephone | 561-826-6650
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Fax | 561-826-6649
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Authorized Official
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Title or Position | PRESIDENT
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Name | FAWN WINKELMAN
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Credential | DO
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Telephone | 561-826-6650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS1629
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License Number State | FL
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