Provider Demographics
NPI:1134288178
Name:LAKES DERMATOLOGY SKIN CANCER & LASER CENTER INC
Entity Type:Organization
Organization Name:LAKES DERMATOLOGY SKIN CANCER & LASER CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:RUECKL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-869-6667
Mailing Address - Street 1:8937 W SAHARA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117
Mailing Address - Country:US
Mailing Address - Phone:702-869-6667
Mailing Address - Fax:702-869-2627
Practice Address - Street 1:8937 W SAHARA AVE
Practice Address - Street 2:STE B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117
Practice Address - Country:US
Practice Address - Phone:702-869-6667
Practice Address - Fax:702-869-2627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV33652Medicare PIN
NVC96528Medicare UPIN