Healthcare Provider Details

I. General information

NPI: 1053705228
Provider Name (Legal Business Name): BEVERLY HILLS WELLNESS PHYSICIANS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 28TH ST STE 100
LONG BEACH CA
90806-2769
US

IV. Provider business mailing address

7230 MEDICAL CENTER DRIVE SUITE 302
WEST HILLS CA
91307
US

V. Phone/Fax

Practice location:
  • Phone: 562-426-2551
  • Fax: 818-337-2049
Mailing address:
  • Phone: 818-548-5980
  • Fax: 818-337-2049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License NumberG28478
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberG44674
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG44674
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11755
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberG44674
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT77740
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberG56249
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA063319
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG56249
License Number StateCA
# 10
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberG44674
License Number StateCA

VIII. Authorized Official

Name: EDWARD BRENT LAUGESON
Title or Position: MANAGER
Credential:
Phone: 818-518-5980