Provider Demographics
NPI:1881754224
Name:UNIQUE DERMATOLOGY & WELLNESS CENTER PA
Entity type:Organization
Organization Name:UNIQUE DERMATOLOGY & WELLNESS CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DYAN
Authorized Official - Middle Name:JENELLE
Authorized Official - Last Name:HARVEY-DENT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-684-9600
Mailing Address - Street 1:4325 LYNX PAW TRL
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-7426
Mailing Address - Country:US
Mailing Address - Phone:813-684-9600
Mailing Address - Fax:813-662-9777
Practice Address - Street 1:4325 LYNX PAW TRL
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-7426
Practice Address - Country:US
Practice Address - Phone:813-684-9600
Practice Address - Fax:813-662-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8642261QP2300X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU2552ZOtherSUPPLIER #
FL271359400Medicaid