Healthcare Provider Details

I. General information

NPI: 1508651068
Provider Name (Legal Business Name): PLASTIC REJUVENATION MEDICAL PROFESSIONAL/CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25408 CRENSHAW BLVD
TORRANCE CA
90505
US

IV. Provider business mailing address

600 N MOUNTAIN AVE SUITE B100
UPLAND CA
91786
US

V. Phone/Fax

Practice location:
  • Phone: 818-518-5980
  • Fax:
Mailing address:
  • Phone: 818-518-5980
  • Fax: 818-337-2069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DENNIS ALWEN
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 818-518-5980