Healthcare Provider Details

I. General information

NPI: 1104548304
Provider Name (Legal Business Name): LA LASER CENTER PC, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N ESTRELLA PKWY STE 210
GOODYEAR AZ
85338-9330
US

IV. Provider business mailing address

PO BOX 16297
BEVERLY HILLS CA
90209-2297
US

V. Phone/Fax

Practice location:
  • Phone: 623-283-6000
  • Fax:
Mailing address:
  • Phone: 661-388-5240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DANIEL TAHERI
Title or Position: OWNER
Credential: MD
Phone: 661-388-5240