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General NPI Number Information
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NPI Number | 1962941211
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Entity Type | Organization
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Legal Business Name | DERMATHERAPY OF SOUTHEAST TEXAS
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Dates
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Enumeration Date | 02/20/2017
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Last Update Date | 02/20/2017
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Provider Practice Location Address
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Address Line | 730 N MAIN ST SUITE A
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City | LUMBERTON
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State | TX
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Zip | 77657-7355
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Country | US
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Telephone | 409-234-6677
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Fax | 409-351-3262
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Provider Business Mailing Address
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Address Line | 5350 OLD DOWLEN RD #114
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City | BEAUMONT
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State | TX
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Zip | 77706-6620
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MR. TRENT C CAMERON
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Credential | FNP
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Telephone | 409-651-4695
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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