Provider Demographics
NPI:1679509152
Name:DERMATOLOGY & LASER CENTER OF FORT COLLINS LLC
Entity Type:Organization
Organization Name:DERMATOLOGY & LASER CENTER OF FORT COLLINS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KORNFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-482-9001
Mailing Address - Street 1:1006 CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1849
Mailing Address - Country:US
Mailing Address - Phone:970-482-9001
Mailing Address - Fax:970-482-1411
Practice Address - Street 1:1006 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1849
Practice Address - Country:US
Practice Address - Phone:970-482-9001
Practice Address - Fax:970-482-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27691207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC287208Medicare ID - Type Unspecified
WYW307845Medicare PIN