MEDICARE: LAGUNA AESTHETICS & FAMILY WELLNESS 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	208600000X	Surgery Physician
2	207QA0505X	Adult Medicine Physician

General Provider Information

NPI Number	:	1881060135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAGUNA AESTHETICS & FAMILY WELLNESS CENTER, INC

Provider Business Mailing Address
First Line	:	1100 S COAST HWY
Second Line	:	SUITE 212
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-2968
Country	:	US
Telephone Number	:	949-632-8087
Fax Number	:	949-715-5889

Provider Business Practice Location Address
First Line	:	1100 S COAST HWY
Second Line	:	SUITE 212
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-2968
Country	:	US
Telephone Number	:	949-632-8087
Fax Number	:	949-715-5889

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	AMANDA MIYAWAKI
Credential	:
Telephone Number	:	949-632-8087

Provider Enumeration Date	:	08/20/2015
Last Update Date	:	08/20/2015

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