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General NPI Number Information
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NPI Number | 1306245980
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Entity Type | Organization
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Legal Business Name | HIGH TIDE DERMATOLOGY CENTER LLC
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Dates
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Enumeration Date | 08/19/2014
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Last Update Date | 08/19/2014
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Provider Practice Location Address
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Address Line | 221 HARBOUR DR
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City | NAPLES
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State | FL
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Zip | 34103-4027
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Country | US
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Telephone | 443-871-2407
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Fax |
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Provider Business Mailing Address
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Address Line | 221 HARBOUR DR
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City | NAPLES
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State | FL
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Zip | 34103-4027
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Country | US
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Telephone | 443-871-2407
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DEBRA LYNN BAILEY
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Credential | M.D.
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Telephone | 443-871-2407
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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 | ME106898
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License Number State | FL
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