Provider Demographics
NPI:1336128164
Name:CLEVELAND SKIN PATHOLOGY LABORATORY, INC
Entity Type:Organization
Organization Name:CLEVELAND SKIN PATHOLOGY LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING & PE
Authorized Official - Prefix:
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLADARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-514-5822
Mailing Address - Street 1:11025 RCA CENTER DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410
Mailing Address - Country:US
Mailing Address - Phone:561-514-5822
Mailing Address - Fax:
Practice Address - Street 1:3737 PARK EAST DRIVE
Practice Address - Street 2:SUITE #202
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-464-7770
Practice Address - Fax:216-464-7531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCLIA 36D0656050207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36D0656050OtherCLIA
OH0252560Medicaid
OH0252560Medicaid