Provider Demographics
NPI:1497270664
Name:SKIN CONCIERGE, LLC.
Entity Type:Organization
Organization Name:SKIN CONCIERGE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DESTINY
Authorized Official - Middle Name:GYPSYLEE
Authorized Official - Last Name:MATTOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-333-5973
Mailing Address - Street 1:1310 W SAINT MARYS RD STE A
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-3231
Mailing Address - Country:US
Mailing Address - Phone:520-333-5973
Mailing Address - Fax:520-221-2318
Practice Address - Street 1:1310 W. ST. MARY'S ROAD
Practice Address - Street 2:2ND FLOOR, SUITE A
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745
Practice Address - Country:US
Practice Address - Phone:520-333-5973
Practice Address - Fax:520-221-2318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-09
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ162831Medicaid