Provider Demographics
NPI:1003905001
Name:SKIN CANCER AND DERMATOLOGY INSTITUTE
Entity Type:Organization
Organization Name:SKIN CANCER AND DERMATOLOGY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-336-3624
Mailing Address - Street 1:640 W MOANA LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4997
Mailing Address - Country:US
Mailing Address - Phone:775-324-0699
Mailing Address - Fax:775-888-8067
Practice Address - Street 1:3950 GS RICHARDS BLVD
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-8457
Practice Address - Country:US
Practice Address - Phone:775-882-8777
Practice Address - Fax:775-888-8067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVWQBGCMedicare ID - Type Unspecified