Provider Demographics
NPI:1255513628
Name:ZENLO DERMATOLOGY, INC.
Entity type:Organization
Organization Name:ZENLO DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDEDNT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:ROYAL
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-934-0060
Mailing Address - Street 1:10120 W BROAD ST
Mailing Address - Street 2:SUITE R
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-6709
Mailing Address - Country:US
Mailing Address - Phone:804-934-0060
Mailing Address - Fax:804-934-0024
Practice Address - Street 1:10120 W BROAD ST
Practice Address - Street 2:SUITE R
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6709
Practice Address - Country:US
Practice Address - Phone:804-934-0060
Practice Address - Fax:804-934-0024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051656302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA183408OtherANTHEM
VADD7147OtherMEDICARE/ RAILROAD
VAC09551Medicare PIN