Provider Demographics
NPI:1912912361
Name:PREMIER DERMATOLOGY & SKIN RENEWAL CENTER
Entity type:Organization
Organization Name:PREMIER DERMATOLOGY & SKIN RENEWAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:CLIFTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-273-3376
Mailing Address - Street 1:909 SE 28TH ST
Mailing Address - Street 2:STE 5
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3880
Mailing Address - Country:US
Mailing Address - Phone:479-273-3376
Mailing Address - Fax:479-273-3468
Practice Address - Street 1:909 SE 28TH ST
Practice Address - Street 2:STE 5
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3880
Practice Address - Country:US
Practice Address - Phone:479-273-3376
Practice Address - Fax:479-273-3468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3363207N00000X, 207NP0225X, 207NS0135X
AR207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Not Answered207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Not Answered207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1679521405OtherNPI - MILDRED CLIFTON, MD
AR03060015000OtherQUALCHOICE
ARDC6671Medicare ID - Type UnspecifiedRAILROAD MEDICARE
AR1679521405OtherNPI - MILDRED CLIFTON, MD
ARH77384Medicare UPIN
AR5M432Medicare PIN