Provider Demographics
NPI:1346316395
Name:SUMMERSVILLE SKIN CARE CENTER INC
Entity Type:Organization
Organization Name:SUMMERSVILLE SKIN CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:A
Authorized Official - Last Name:LUCKY
Authorized Official - Suffix:
Authorized Official - Credentials:RNC-FNP
Authorized Official - Phone:304-872-3654
Mailing Address - Street 1:818 ARBUCKLE RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1704
Mailing Address - Country:US
Mailing Address - Phone:304-872-3654
Mailing Address - Fax:
Practice Address - Street 1:818 ARBUCKLE RD
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1704
Practice Address - Country:US
Practice Address - Phone:304-872-3654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV44396363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty