Organization
DESTINATION DERMATOLOGY LLC
Active
Other names
Renew Dermatology
Organization subpart
No
Provider details
NPI number
Authorized official
KELLY BALLOU PA-C (MANAGING MEMBER)
(309) 287-1909
Entity
Organization
Contact information
Practice address
60 MAIN STREET, STE F, G & H, FRISCO, CO 80443
(309) 287-1909
Mailing address
265 DILLON RIDGE RD, STE C402, DILLON, CO 80435-6009
(309) 287-1909
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
Primary
PA0004388
CO
Other
Enumeration date
03/28/2017
Last updated
03/28/2017
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