Provider Demographics
NPI:1114071164
Name:TOTAL SKIN CARE AND LASER CENTER, LLC
Entity Type:Organization
Organization Name:TOTAL SKIN CARE AND LASER CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-951-3429
Mailing Address - Street 1:817 DAVIS ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7013
Mailing Address - Country:US
Mailing Address - Phone:540-951-3429
Mailing Address - Fax:540-951-8887
Practice Address - Street 1:817 DAVIS ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7013
Practice Address - Country:US
Practice Address - Phone:540-951-3429
Practice Address - Fax:540-951-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051261174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA175050OtherANTHEM