Provider Demographics
NPI:1285481986
Name:DERMCLUB X MADISON SHREEVE INC
Entity type:Organization
Organization Name:DERMCLUB X MADISON SHREEVE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MADISON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHREEVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-706-2872
Mailing Address - Street 1:747 DOVER DR STE B
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-6927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:747 DOVER DR STE B
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-6927
Practice Address - Country:US
Practice Address - Phone:979-706-2872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty