Provider Demographics
NPI:1487843199
Name:THE CUTANEOUS LASER CENTER
Entity Type:Organization
Organization Name:THE CUTANEOUS LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SABRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MDPHD
Authorized Official - Phone:601-355-8555
Mailing Address - Street 1:501 MARSHALL ST STE 606
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1650
Mailing Address - Country:US
Mailing Address - Phone:601-355-8555
Mailing Address - Fax:601-355-2244
Practice Address - Street 1:501 MARSHALL ST STE 606
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1650
Practice Address - Country:US
Practice Address - Phone:601-355-8555
Practice Address - Fax:601-355-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT14238207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty