Provider Demographics
NPI:1003823618
Name:PHOTODERMIC, INC.
Entity Type:Organization
Organization Name:PHOTODERMIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-672-4685
Mailing Address - Street 1:PO BOX 3784
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79604-3784
Mailing Address - Country:US
Mailing Address - Phone:325-672-4685
Mailing Address - Fax:325-672-4693
Practice Address - Street 1:3110 N 1ST ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79603-7004
Practice Address - Country:US
Practice Address - Phone:325-672-4685
Practice Address - Fax:325-672-4693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W310Medicare ID - Type UnspecifiedMEDICARE