Provider Demographics
NPI:1093131229
Name:CREEKSIDE SKIN CARE, LLC.
Entity Type:Organization
Organization Name:CREEKSIDE SKIN CARE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:E
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:303-823-3376
Mailing Address - Street 1:8000 E PRENTICE AVE
Mailing Address - Street 2:SUITE D-10
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2744
Mailing Address - Country:US
Mailing Address - Phone:303-823-3376
Mailing Address - Fax:303-683-3306
Practice Address - Street 1:8000 E PRENTICE AVE
Practice Address - Street 2:SUITE D-10
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2744
Practice Address - Country:US
Practice Address - Phone:303-823-3376
Practice Address - Fax:303-683-3306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45274363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty