=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871542787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATER'S EDGE DERMATOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 01/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 VILLAGE SQUARE XING SUITE 201
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-721-2400
-----------------------------------------------------
Fax | 561-721-1249
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 VILLAGE SQUARE XING
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-721-2400
-----------------------------------------------------
Fax | 561-721-1249
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIR BILLING OPERATIONS
-----------------------------------------------------
Name | SUSAN DAVIS
-----------------------------------------------------
Credential | AUTHORIZED OFFICIAL
-----------------------------------------------------
Telephone | 561-693-0540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 800019024
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------