Provider Demographics
NPI:1770196719
Name:SPRING DERM, LLC
Entity Type:Organization
Organization Name:SPRING DERM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSEHOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-529-0072
Mailing Address - Street 1:PO BOX 913
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-0913
Mailing Address - Country:US
Mailing Address - Phone:417-766-8002
Mailing Address - Fax:888-773-3706
Practice Address - Street 1:800 STATE HIGHWAY 248 STE 2C
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-4078
Practice Address - Country:US
Practice Address - Phone:417-766-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPRING DERM, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty