Provider Demographics
NPI:1962952275
Name:SKIN RENAISSANCE
Entity type:Organization
Organization Name:SKIN RENAISSANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:FOSTER
Authorized Official - Last Name:TRASK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:757-410-2833
Mailing Address - Street 1:312 CEDAR LAKES DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-8374
Mailing Address - Country:US
Mailing Address - Phone:757-410-2833
Mailing Address - Fax:757-819-7591
Practice Address - Street 1:312 CEDAR LAKES DR
Practice Address - Street 2:SUITE 103
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-8374
Practice Address - Country:US
Practice Address - Phone:757-410-2833
Practice Address - Fax:757-819-7591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170014261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center