Provider Demographics
NPI:1417241332
Name:CANDESCENT PRESTIGE LLC
Entity type:Organization
Organization Name:CANDESCENT PRESTIGE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JENKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-262-1450
Mailing Address - Street 1:4546 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-5119
Mailing Address - Country:US
Mailing Address - Phone:727-849-1447
Mailing Address - Fax:
Practice Address - Street 1:4546 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-5119
Practice Address - Country:US
Practice Address - Phone:727-849-1447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7718207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty