Provider Demographics
NPI:1205368453
Name:DESTINATION DERMATOLOGY LLC
Entity Type:Organization
Organization Name:DESTINATION DERMATOLOGY LLC
Other - Org Name:RENEW DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLOU
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:309-287-1909
Mailing Address - Street 1:265 DILLON RIDGE RD
Mailing Address - Street 2:STE C402
Mailing Address - City:DILLON
Mailing Address - State:CO
Mailing Address - Zip Code:80435-6009
Mailing Address - Country:US
Mailing Address - Phone:309-287-1909
Mailing Address - Fax:
Practice Address - Street 1:60 MAIN STREET
Practice Address - Street 2:STE F, G & H
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:309-287-1909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0004388261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COQ02483Medicare UPIN
CO207805Medicare PIN