MEDICARE: NEW LIFE MALE MEDICAL CENTER INC.

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	208800000X	Urology Physician	51964	CA

General Provider Information

NPI Number	:	1851800379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW LIFE MALE MEDICAL CENTER INC.

Provider Business Mailing Address
First Line	:	1577 E CHEVY CHASE DR STE 240
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-4742
Country	:	US
Telephone Number	:	818-937-9551
Fax Number	:	818-484-2116

Provider Business Practice Location Address
First Line	:	1577 E CHEVY CHASE DR STE 240
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-4742
Country	:	US
Telephone Number	:	818-937-9551
Fax Number	:	818-484-2116

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. HOWARD LAZERSON
Credential	:	MD
Telephone Number	:	818-937-9551

Provider Enumeration Date	:	09/27/2017
Last Update Date	:	07/21/2022

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