Provider Demographics
NPI:1376125740
Name:SKINLAB 360 DERMATOLOGY & AESTHETICS LLC
Entity Type:Organization
Organization Name:SKINLAB 360 DERMATOLOGY & AESTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-709-0478
Mailing Address - Street 1:PO BOX 3625
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3625
Mailing Address - Country:US
Mailing Address - Phone:800-338-5378
Mailing Address - Fax:208-523-8978
Practice Address - Street 1:117 W MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1826
Practice Address - Country:US
Practice Address - Phone:208-709-0478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty