Healthcare Provider Details

I. General information

NPI: 1760924005
Provider Name (Legal Business Name): ELITE PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12732 W WASHINGTON BLVD STE B
LOS ANGELES CA
90066-2378
US

IV. Provider business mailing address

12732 W WASHINGTON BLVD STE B
LOS ANGELES CA
90066-2378
US

V. Phone/Fax

Practice location:
  • Phone: 310-275-4170
  • Fax:
Mailing address:
  • Phone: 310-275-4170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEENETH B HUGHES
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 310-275-4170