Healthcare Provider Details

I. General information

NPI: 1659093599
Provider Name (Legal Business Name): MENIFEE LASER CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29798 HAUN RD. SUITE 209
MENIFEE CA
92586
US

IV. Provider business mailing address

P.O. BOX 966
SUNCITY CA
92586
US

V. Phone/Fax

Practice location:
  • Phone: 951-672-4200
  • Fax: 951-672-0835
Mailing address:
  • Phone: 951-672-4200
  • Fax: 951-672-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. VADIM GURVITS
Title or Position: PRESIDENT
Credential: D.O.
Phone: 951-672-4200