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General NPI Number Information
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NPI Number | 1336439553
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Entity Type | Organization
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Legal Business Name | ADVANCED DERMATOLOGY CARE A PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 04/08/2011
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Last Update Date | 07/12/2018
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Provider Practice Location Address
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Address Line | 2409 BROADMOOR BLVD
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City | MONROE
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State | LA
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Zip | 71201-2964
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Country | US
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Telephone | 318-323-8799
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Fax | 318-323-8815
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Provider Business Mailing Address
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Address Line | 1868 FORSYTHE AVE STE 335
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City | MONROE
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State | LA
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Zip | 71201-3540
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Country | US
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Telephone | 318-323-8799
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LORETTA PYLANT GREMILLION
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Credential | M.D.
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Telephone | 318-323-8799
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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 | 026501
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License Number State | LA
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