Provider Demographics
NPI:1306117460
Name:SKINPATH DIAGNOSTICS LLC
Entity type:Organization
Organization Name:SKINPATH DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATHERNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-446-5888
Mailing Address - Street 1:3000 KNIGHT STREET
Mailing Address - Street 2:BLDG 5 SUITE 220
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-841-9526
Mailing Address - Fax:318-841-9551
Practice Address - Street 1:3000 KNIGHT STREET
Practice Address - Street 2:BLDG 5 SUITE 220
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-841-9526
Practice Address - Fax:318-841-9551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-21
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1500615Medicaid