Provider Demographics
NPI:1568515898
Name:SKIN WELLNESS CENTER PC
Entity Type:Organization
Organization Name:SKIN WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-251-9942
Mailing Address - Street 1:10215 KINGSTON PIKE # 200
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3222
Mailing Address - Country:US
Mailing Address - Phone:865-584-8580
Mailing Address - Fax:865-251-9961
Practice Address - Street 1:10215 KINGSTON PIKE # 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3222
Practice Address - Country:US
Practice Address - Phone:865-584-8580
Practice Address - Fax:865-251-9961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729191Medicare ID - Type Unspecified