| NPI | 1073954913 |
|---|---|
| Former Legal Business Name | JORDAN VALLEY DERMATOLOGY |
| Entity Type | Organization |
| Authorized Contact | VIRGINIA LOUISE TUBBS Owner 307-265-2936 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: UT 8624096-4405) |
| Enumeration Date | 2013-07-08 |
| Last Update Date | 2019-06-21 |