Provider Demographics
NPI:1801227327
Name:MOD SKIN AND BODY CLINIC
Entity Type:Organization
Organization Name:MOD SKIN AND BODY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:TABARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-406-8455
Mailing Address - Street 1:14130 JUANITA DR NE STE 110
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-0127
Mailing Address - Country:US
Mailing Address - Phone:425-406-8455
Mailing Address - Fax:
Practice Address - Street 1:14130 JUANITA DR NE STE 110
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-0127
Practice Address - Country:US
Practice Address - Phone:425-406-8455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty