Provider Demographics
NPI:1952724213
Name:BEYOUTIFUL SKIN AND LASER CENTER
Entity Type:Organization
Organization Name:BEYOUTIFUL SKIN AND LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GM
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-877-3568
Mailing Address - Street 1:4066 HIXSON PIKE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-3110
Mailing Address - Country:US
Mailing Address - Phone:423-877-3568
Mailing Address - Fax:423-877-9332
Practice Address - Street 1:4066 HIXSON PIKE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-3110
Practice Address - Country:US
Practice Address - Phone:423-877-3568
Practice Address - Fax:423-877-9332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000981363AM0700X
TN8749977363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty