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General NPI Number Information
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NPI Number | 1205368453
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Entity Type | Organization
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Legal Business Name | DESTINATION DERMATOLOGY LLC
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Dates
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Enumeration Date | 03/28/2017
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Last Update Date | 03/28/2017
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Provider Practice Location Address
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Address Line | 60 MAIN STREET STE F, G & H
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City | FRISCO
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State | CO
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Zip | 80443
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Country | US
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Telephone | 309-287-1909
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Fax |
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Provider Business Mailing Address
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Address Line | 265 DILLON RIDGE RD STE C402
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City | DILLON
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State | CO
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Zip | 80435-6009
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Country | US
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Telephone | 309-287-1909
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | KELLY BALLOU
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Credential | PA-C
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Telephone | 309-287-1909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | PA0004388
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License Number State | CO
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