Provider Demographics
NPI:1356593545
Name:ACNE & ROSACEA CLINICS
Entity type:Organization
Organization Name:ACNE & ROSACEA CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-668-5000
Mailing Address - Street 1:907 VANN DRIVE STE M
Mailing Address - Street 2:PO BOX 11537
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38012-6046
Mailing Address - Country:US
Mailing Address - Phone:731-668-5000
Mailing Address - Fax:731-668-5122
Practice Address - Street 1:907 VANN DRIVE SUITE M
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6046
Practice Address - Country:US
Practice Address - Phone:731-668-5000
Practice Address - Fax:731-668-5122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN8135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3906025Medicaid
TN3906025Medicare PIN
TNP55449Medicare UPIN