=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467520775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY & WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 07/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9150 ESTATE THOMAS SUITE 106
-----------------------------------------------------
City | ST THOMAS
-----------------------------------------------------
State | VI
-----------------------------------------------------
Zip | 00802-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 340-776-2544
-----------------------------------------------------
Fax | 340-774-2677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11366
-----------------------------------------------------
City | ST THOMAS
-----------------------------------------------------
State | VI
-----------------------------------------------------
Zip | 00801-4366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 340-776-2544
-----------------------------------------------------
Fax | 340-774-2677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JAMES FLETCHER ROBINSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 340-776-2544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 461
-----------------------------------------------------
License Number State | VI
-----------------------------------------------------