Provider Demographics
NPI:1003215955
Name:CLEAR SKIN MEDICAL SOLUTIONS, LLC
Entity Type:Organization
Organization Name:CLEAR SKIN MEDICAL SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:870-204-5346
Mailing Address - Street 1:PO BOX 1102
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-1102
Mailing Address - Country:US
Mailing Address - Phone:870-204-5346
Mailing Address - Fax:870-365-0481
Practice Address - Street 1:715 W SHERMAN AVE
Practice Address - Street 2:SUITE H
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2743
Practice Address - Country:US
Practice Address - Phone:870-204-5346
Practice Address - Fax:870-365-0481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA001877363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190397758Medicaid