Provider Demographics
NPI:1467908863
Name:CLINIC FOR DERMATOLOGY & WELLNESS LLC
Entity Type:Organization
Organization Name:CLINIC FOR DERMATOLOGY & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ATZENBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-200-2777
Mailing Address - Street 1:2924 SISKIYOU BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6462
Mailing Address - Country:US
Mailing Address - Phone:541-200-2777
Mailing Address - Fax:541-214-2575
Practice Address - Street 1:2924 SISKIYOU BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6462
Practice Address - Country:US
Practice Address - Phone:541-200-2793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty