Provider Demographics
NPI:1588802391
Name:ALPINE DERMATOLOGY CLINIC P.C.
Entity Type:Organization
Organization Name:ALPINE DERMATOLOGY CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-359-4841
Mailing Address - Street 1:1049 SUMMERS DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5335
Mailing Address - Country:US
Mailing Address - Phone:208-359-4841
Mailing Address - Fax:
Practice Address - Street 1:1049 SUMMERS DR
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5335
Practice Address - Country:US
Practice Address - Phone:208-359-4841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-02
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0508261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty