Healthcare Provider Details

I. General information

NPI: 1306203237
Provider Name (Legal Business Name): REVERSE AGING CENTRE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 N ROXBURY DR
BEVERLY HILLS CA
90210-5001
US

IV. Provider business mailing address

455 N ROXBURY DR
BEVERLY HILLS CA
90210-5001
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-1166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberAS1422651
License Number StateCA

VIII. Authorized Official

Name: DR. MAX SAWAF
Title or Position: CHAIRMAN AND CEO
Credential: M.D
Phone: 310-273-1166