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General NPI Number Information
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NPI Number | 1346316395
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Entity Type | Organization
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Legal Business Name | SUMMERSVILLE SKIN CARE CENTER INC
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 07/21/2011
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Provider Practice Location Address
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Address Line | 818 ARBUCKLE RD
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City | SUMMERSVILLE
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State | WV
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Zip | 26651-1704
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Country | US
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Telephone | 304-872-3654
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Fax |
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Provider Business Mailing Address
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Address Line | 818 ARBUCKLE RD
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City | SUMMERSVILLE
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State | WV
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Zip | 26651-1704
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Country | US
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Telephone | 304-872-3654
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | DELORES A LUCKY
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Credential | RNC-FNP
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Telephone | 304-872-3654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 44396
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License Number State | WV
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