Healthcare Provider Details

I. General information

NPI: 1235403866
Provider Name (Legal Business Name): LOS ANGELES CENTER FOR MEDICAL WEIGHT LOSS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 W AVENUE Q SUITE A
PALMDALE CA
93551-3890
US

IV. Provider business mailing address

623 W AVENUE Q SUITE A
PALMDALE CA
93551-3890
US

V. Phone/Fax

Practice location:
  • Phone: 661-726-6255
  • Fax: 661-726-6261
Mailing address:
  • Phone: 661-726-6255
  • Fax: 661-726-6261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License NumberA48894
License Number StateCA

VIII. Authorized Official

Name: DR. PAMELA DE SIVLA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 661-726-6255