Provider Demographics
NPI:1407992373
Name:MY SKIN CLINICS PLC
Entity Type:Organization
Organization Name:MY SKIN CLINICS PLC
Other - Org Name:REBE SKIN AND VEIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOLEGRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-332-6001
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:OKOBOJI
Mailing Address - State:IA
Mailing Address - Zip Code:51355-0125
Mailing Address - Country:US
Mailing Address - Phone:712-332-6001
Mailing Address - Fax:712-332-6010
Practice Address - Street 1:3301 HIGHWAY 71 UNIT 1&4
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-7634
Practice Address - Country:US
Practice Address - Phone:712-332-6001
Practice Address - Fax:712-332-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24582202K00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADO5034OtherRAILROAD MEDICARE
IA0746875Medicaid
IADO5034OtherRAILROAD MEDICARE
6173170001Medicare NSC