Provider Demographics
NPI:1942593264
Name:RADIANT COMPLEXIONS DERMATOLOGY CLINIC OF COUNCIL BLUFFS, PLC
Entity Type:Organization
Organization Name:RADIANT COMPLEXIONS DERMATOLOGY CLINIC OF COUNCIL BLUFFS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-226-8484
Mailing Address - Street 1:900 WOODBURY AVE
Mailing Address - Street 2:SUITE 5B
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-7847
Mailing Address - Country:US
Mailing Address - Phone:712-352-2678
Mailing Address - Fax:888-557-0763
Practice Address - Street 1:900 WOODBURY AVE
Practice Address - Street 2:SUITE 5B
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-7847
Practice Address - Country:US
Practice Address - Phone:712-352-2678
Practice Address - Fax:888-557-0763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty