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General NPI Number Information
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NPI Number | 1184600884
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Entity Type | Organization
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Legal Business Name | NORTH VALLEY DERMATOLOGY LLC
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Dates
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Enumeration Date | 12/15/2005
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Last Update Date | 09/12/2011
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Provider Practice Location Address
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Address Line | 14155 N 83RD AVE SUITE 110
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City | PEORIA
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State | AZ
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Zip | 85381-5639
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Country | US
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Telephone | 623-215-0911
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Fax | 623-215-0912
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Provider Business Mailing Address
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Address Line | 14155 N 83RD AVE SUITE 110
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City | PEORIA
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State | AZ
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Zip | 85381-5639
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Country | US
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Telephone | 623-215-0911
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Fax | 623-215-0912
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MARY F FREDENBERG
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Credential | MD
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Telephone | 623-215-0911
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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 | 16095
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License Number State | AZ
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