Provider Demographics
NPI:1104668219
Name:THE SKIN & WELLNESS CENTER PLLC
Entity type:Organization
Organization Name:THE SKIN & WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:910-809-0030
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:125 S MAIN ST SUITE A
Mailing Address - City:BLADENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28320
Mailing Address - Country:US
Mailing Address - Phone:910-809-0030
Mailing Address - Fax:
Practice Address - Street 1:125 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:BLADENBORO
Practice Address - State:NC
Practice Address - Zip Code:28320-8440
Practice Address - Country:US
Practice Address - Phone:910-809-0030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1992795041Medicaid