Provider Demographics
NPI:1164164141
Name:DERM HAVEN INC
Entity Type:Organization
Organization Name:DERM HAVEN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSSALLY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:435-695-8585
Mailing Address - Street 1:782 S RIVER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5716
Mailing Address - Country:US
Mailing Address - Phone:435-695-8585
Mailing Address - Fax:
Practice Address - Street 1:352 E RIVERSIDE DR STE A3
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6759
Practice Address - Country:US
Practice Address - Phone:435-695-8585
Practice Address - Fax:435-900-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty