MEDICARE: LA LASER CENTER PC, A PROFESSIONAL MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1083248850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA LASER CENTER PC, A PROFESSIONAL MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 16297
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90209-2297
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2580 HIGHWAY 95 STE 224
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7332
Country	:	US
Telephone Number	:	928-608-5420
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DANIEL TAHERI
Credential	:
Telephone Number	:	310-922-1412

Provider Enumeration Date	:	03/02/2020
Last Update Date	:	01/20/2024

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