Provider Demographics
NPI:1417334806
Name:SKIN HDC
Entity Type:Organization
Organization Name:SKIN HDC
Other - Org Name:SKIN HOLISTIC DERMAGRAPHIC CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:REGISTERED NURSE, CEO
Authorized Official - Prefix:
Authorized Official - First Name:GYWNN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFSTAR
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, BA
Authorized Official - Phone:303-440-6611
Mailing Address - Street 1:413 SUMMIT BLVD
Mailing Address - Street 2:UNIT 104
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-8294
Mailing Address - Country:US
Mailing Address - Phone:303-440-6611
Mailing Address - Fax:720-550-8995
Practice Address - Street 1:413 SUMMIT BLVD
Practice Address - Street 2:UNIT 104
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-8294
Practice Address - Country:US
Practice Address - Phone:303-440-6611
Practice Address - Fax:720-550-8995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0100256314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
12767902OtherCAQH