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General NPI Number Information
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NPI Number | 1477169753
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Entity Type | Organization
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Legal Business Name | HEARTHSTONE DERMATOLOGY NONPROFIT PROFESSIONAL SERVICES
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Dates
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Enumeration Date | 09/22/2020
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Last Update Date | 09/22/2020
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Provider Practice Location Address
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Address Line | 828 MOX CHEHALIS RD
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City | MCCLEARY
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State | WA
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Zip | 98557-9408
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Country | US
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Telephone | 360-470-0671
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Fax | 360-464-2617
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Provider Business Mailing Address
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Address Line | 828 MOX CHEHALIS RD
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City | MCCLEARY
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State | WA
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Zip | 98557-9408
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Country | US
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Telephone | 360-470-0671
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Fax | 360-464-2617
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Authorized Official
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Title or Position | CEO-ADMINISTRATOR
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Name | GENEVA TZENOV
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Credential | FNP-C
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Telephone | 360-470-0671
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number |
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License Number State |
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