Provider Demographics
NPI:1578206785
Name:SUMMIT DERMATOLOGY AND SPA LLC
Entity Type:Organization
Organization Name:SUMMIT DERMATOLOGY AND SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-518-3881
Mailing Address - Street 1:3298 SUMMIT BLVD STE 12
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-4350
Mailing Address - Country:US
Mailing Address - Phone:850-746-0650
Mailing Address - Fax:850-746-0651
Practice Address - Street 1:3298 SUMMIT BLVD STE 12
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-4350
Practice Address - Country:US
Practice Address - Phone:850-518-3881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-15
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018326600Medicaid