Healthcare Provider Details

I. General information

NPI: 1285481259
Provider Name (Legal Business Name): LE SHANGRI LA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7545 E ANGUS DR
SCOTTSDALE AZ
85251-6409
US

IV. Provider business mailing address

7545 E ANGUS DR
SCOTTSDALE AZ
85251-6409
US

V. Phone/Fax

Practice location:
  • Phone: 480-664-0125
  • Fax: 480-664-0219
Mailing address:
  • Phone: 480-664-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRYAN FRIEDMAN
Title or Position: OWNER
Credential: DO
Phone: 480-664-0125