Provider Demographics
NPI:1902668171
Name:PURE DERMATOLOGY LLC
Entity Type:Organization
Organization Name:PURE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:801-475-3090
Mailing Address - Street 1:466 E 500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3342
Mailing Address - Country:US
Mailing Address - Phone:801-475-3090
Mailing Address - Fax:
Practice Address - Street 1:466 E 500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3342
Practice Address - Country:US
Practice Address - Phone:801-475-3090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty