Provider Demographics
NPI:1023581055
Name:DERMACLINICAL, INC.
Entity type:Organization
Organization Name:DERMACLINICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-515-3349
Mailing Address - Street 1:7154 W STATE ST STE 397
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-7421
Mailing Address - Country:US
Mailing Address - Phone:208-515-3349
Mailing Address - Fax:208-692-8388
Practice Address - Street 1:7154 W STATE ST STE 397
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-7421
Practice Address - Country:US
Practice Address - Phone:208-515-3349
Practice Address - Fax:208-692-8388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-02
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies