MEDICARE: LONG BEACH MEDISPA MANAGEMENT, 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	332900000X	Non-Pharmacy Dispensing Site	G73514	CA

General Provider Information

NPI Number	:	1932583085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG BEACH MEDISPA MANAGEMENT, INC.

Provider Business Mailing Address
First Line	:	2980 N BEVERLY GLEN CIR
Second Line	:	SUITE 301
City	:	LOS ANGELES
State	:	CA
Zip	:	90077-1726
Country	:	US
Telephone Number	:	310-943-4180
Fax Number	:	888-431-8819

Provider Business Practice Location Address
First Line	:	2370 LONG BEACH BLVD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-3260
Country	:	US
Telephone Number	:	562-612-0950
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DAVID S SILVER
Credential	:	M.D.
Telephone Number	:	562-612-0950

Provider Enumeration Date	:	07/17/2015
Last Update Date	:	08/25/2015

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