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General NPI Number Information
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NPI Number | 1497159453
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Entity Type | Organization
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Legal Business Name | PINE BELT DERMATOLOGY AND SKIN CANCER CENTER
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Dates
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Enumeration Date | 10/20/2014
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Last Update Date | 10/20/2014
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Provider Practice Location Address
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Address Line | 201 S MAIN ST
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City | PETAL
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State | MS
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Zip | 39465-2362
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Country | US
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Telephone | 513-267-3658
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Fax |
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Provider Business Mailing Address
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Address Line | 201 S MAIN ST
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City | PETAL
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State | MS
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Zip | 39465-2362
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Country | US
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Telephone | 513-267-3658
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. JOY LYNN MOORE
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Credential |
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Telephone | 513-267-3658
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 21178
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License Number State | MS
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