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General NPI Number Information
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NPI Number | 1275198913
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Entity Type | Organization
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Legal Business Name | RENEW FAMILY DERMATOLOGY LLC
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Dates
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Enumeration Date | 05/08/2019
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Last Update Date | 03/05/2026
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Provider Practice Location Address
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Address Line | 212 AIRPORT ROAD W
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City | FORT PAYNE
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State | AL
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Zip | 35968
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Country | US
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Telephone | 256-979-1250
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Fax | 256-979-1251
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Provider Business Mailing Address
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Address Line | 212 AIRPORT RD W
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City | FORT PAYNE
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State | AL
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Zip | 35968-3335
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Country | US
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Telephone | 256-979-1250
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Fax | 256-979-1251
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Authorized Official
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Title or Position | MANAGER
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Name | PAM MASON
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Credential |
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Telephone | 256-867-0851
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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 |
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License Number State |
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Taxonomy #2
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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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