Provider Demographics
NPI:1083845853
Name:EXPRESSCARE HEALTH AND SKIN CENTER
Entity Type:Organization
Organization Name:EXPRESSCARE HEALTH AND SKIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JITKA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:671-689-8997
Mailing Address - Street 1:PO BOX 3128
Mailing Address - Street 2:
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96932-3128
Mailing Address - Country:US
Mailing Address - Phone:671-477-2873
Mailing Address - Fax:671-472-2873
Practice Address - Street 1:302 S ROUTE 4
Practice Address - Street 2:AGANA SHOPPING CENTER SUITE 207
Practice Address - City:CHALAN PAGO
Practice Address - State:GU
Practice Address - Zip Code:96910
Practice Address - Country:US
Practice Address - Phone:671-477-2873
Practice Address - Fax:671-472-2873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM1288261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center