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General NPI Number Information
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NPI Number | 1144782939
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Entity Type | Organization
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Legal Business Name | PACIFIC ANTI AGING MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 04/02/2019
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Last Update Date | 07/23/2020
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Provider Practice Location Address
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Address Line | 215 S LA CIENEGA BLVD STE 207
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City | BEVERLY HILLS
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State | CA
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Zip | 90211-3322
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Country | US
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Telephone | 310-272-4395
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Fax | 866-284-5217
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Provider Business Mailing Address
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Address Line | 215 S LA CIENEGA BLVD STE 207
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City | BEVERLY HILLS
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State | CA
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Zip | 90211-3322
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Country | US
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Telephone | 310-272-4395
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Fax | 866-284-5217
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Authorized Official
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Title or Position | CEO/OWNER
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Name | LANDON C. MCCARROLL
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Credential |
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Telephone | 310-272-4395
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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