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General NPI Number Information
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NPI Number | 1417241332
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Entity Type | Organization
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Legal Business Name | CANDESCENT PRESTIGE LLC
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Dates
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Enumeration Date | 06/08/2011
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Last Update Date | 06/08/2011
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Provider Practice Location Address
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Address Line | 4546 GRAND BLVD
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City | NEW PORT RICHEY
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State | FL
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Zip | 34652-5119
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Country | US
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Telephone | 727-849-1447
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Fax |
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Provider Business Mailing Address
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Address Line | 4546 GRAND BLVD
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City | NEW PORT RICHEY
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State | FL
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Zip | 34652-5119
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Country | US
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Telephone | 727-849-1447
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Fax |
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Authorized Official
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Title or Position | DIRECTOR/CEO
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Name | MR. STEPHEN M JENKS
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Credential |
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Telephone | 617-262-1450
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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 | OS7718
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License Number State | FL
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