Provider Demographics
NPI:1477221364
Name:GLOW THEORY DERMATOLOGY INC
Entity Type:Organization
Organization Name:GLOW THEORY DERMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:INSIYAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DARUGAR
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:859-912-1906
Mailing Address - Street 1:7750 EL CAMINO REAL STE F
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-8517
Mailing Address - Country:US
Mailing Address - Phone:888-456-9843
Mailing Address - Fax:
Practice Address - Street 1:7750 EL CAMINO REAL STE F
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-8517
Practice Address - Country:US
Practice Address - Phone:888-456-9843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service