MEDICARE: PHOTODERMIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		TX

General Provider Information

NPI Number	:	1003823618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOTODERMIC, INC.

Provider Business Mailing Address
First Line	:	PO BOX 3784
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79604-3784
Country	:	US
Telephone Number	:	325-672-4685
Fax Number	:	325-672-4693

Provider Business Practice Location Address
First Line	:	3110 N 1ST ST
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79603-7004
Country	:	US
Telephone Number	:	325-672-4685
Fax Number	:	325-672-4693

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. LADONNA PHARRIS
Credential	:
Telephone Number	:	325-672-4685

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	07/21/2022

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