MEDICARE: HOLLYWOOD LIFESTYLE DERMAOTOGY

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	261Q00000X	Clinic/Center	20A 8743	CA

General Provider Information

NPI Number	:	1740695139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLYWOOD LIFESTYLE DERMAOTOGY

Provider Business Mailing Address
First Line	:	7135 HOLLYWOOD BLVD
Second Line	:	#306
City	:	LOS ANGELES
State	:	CA
Zip	:	90046-3212
Country	:	US
Telephone Number	:	323-301-3378
Fax Number	:	213-256-0685

Provider Business Practice Location Address
First Line	:	7135 HOLLYWOOD BLVD
Second Line	:	#306
City	:	LOS ANGELES
State	:	CA
Zip	:	90046-3212
Country	:	US
Telephone Number	:	323-301-3378
Fax Number	:	213-256-0685

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL J SABAT
Credential	:	D.O.
Telephone Number	:	323-600-4156

Provider Enumeration Date	:	06/24/2014
Last Update Date	:	06/24/2014

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