=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679242457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEEBERGER DERMATOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2021
-----------------------------------------------------
Last Update Date | 04/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 10TH ST STE C
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-5012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-405-9886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 10TH ST STE C
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-5012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-437-4533
-----------------------------------------------------
Fax | 575-437-5009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ROBERT BONN SEEBERGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-841-8300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------