=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811738735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LACREMETA LLC DBA GJ SKIN CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2024
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13549 US HIGHWAY 87 W UNIT B
-----------------------------------------------------
City | LA VERNIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78121-5879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-251-8232
-----------------------------------------------------
Fax | 908-282-3628
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13549 US HIGHWAY 87 W UNIT B
-----------------------------------------------------
City | LA VERNIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78121-5879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-251-8232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | GALINA WARREN
-----------------------------------------------------
Credential | ANP
-----------------------------------------------------
Telephone | 830-251-8232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------