MEDICARE: ELITE PLASTIC SURGERY

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1760924005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE PLASTIC SURGERY

Provider Business Mailing Address
First Line	:	12732 W WASHINGTON BLVD STE B
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-2378
Country	:	US
Telephone Number	:	310-275-4170
Fax Number	:

Provider Business Practice Location Address
First Line	:	12732 W WASHINGTON BLVD STE B
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-2378
Country	:	US
Telephone Number	:	310-275-4170
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	KEENETH B HUGHES
Credential	:	MD
Telephone Number	:	310-275-4170

Provider Enumeration Date	:	11/16/2016
Last Update Date	:	11/16/2016

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Directions to “ELITE PLASTIC SURGERY ” Practice Location

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