MEDICARE: BODYLOGICMD OF BEVELY HILLS

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1669913661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODYLOGICMD OF BEVELY HILLS

Provider Business Mailing Address
First Line	:	9744 WILSHIRE BLVD
Second Line	:	SUITE 200
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90212-1828
Country	:	US
Telephone Number	:	310-760-8268
Fax Number	:	877-709-9034

Provider Business Practice Location Address
First Line	:	9744 WILSHIRE BLVD
Second Line	:	SUITE 200
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90212
Country	:	US
Telephone Number	:	310-760-8268
Fax Number	:	877-709-9034

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NICOLE ANN GARCIA
Credential	:	MD
Telephone Number	:	714-396-2747

Provider Enumeration Date	:	03/10/2017
Last Update Date	:	03/10/2017

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