=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720230840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAVE PLASTIC SURGERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2008
-----------------------------------------------------
Last Update Date | 05/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3680 WILSHIRE BLVD STE 202
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-383-4800
-----------------------------------------------------
Fax | 213-674-2827
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3680 WILSHIRE BLVD STE 202
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-383-4800
-----------------------------------------------------
Fax | 213-674-2827
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PLASTIC SURGEON
-----------------------------------------------------
Name | DR. PETER G. LEE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 213-383-4800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 284300000X
-----------------------------------------------------
Taxonomy Name | Special Hospital
-----------------------------------------------------
License Number | G84673
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------