MEDICARE: ELEGANT SKIN CARE MEDICAL CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	20A8453	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20A8453	OTHER	CA	CERTIFICATE

General Provider Information

NPI Number	:	1598772337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEGANT SKIN CARE MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	1117 N HOLLYWOOD WAY
Second Line	:	B
City	:	BURBANK
State	:	CA
Zip	:	91505-2528
Country	:	US
Telephone Number	:	818-955-9550
Fax Number	:	818-955-9507

Provider Business Practice Location Address
First Line	:	1117 N HOLLYWOOD WAY
Second Line	:	B
City	:	BURBANK
State	:	CA
Zip	:	91505-2528
Country	:	US
Telephone Number	:	818-955-9550
Fax Number	:	818-955-9507

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	DR. ALBERT M KELLY
Credential	:	D.O.
Telephone Number	:	818-955-9550

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	08/22/2020

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