MEDICARE: BIOVISAGE ACUPUNCTURE FACELIFT CLINIC

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	171100000X	Acupuncturist	AC6481	CA

General Provider Information

NPI Number	:	1952526873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIOVISAGE ACUPUNCTURE FACELIFT CLINIC

Provider Business Mailing Address
First Line	:	3660 AMESBURY RD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-1304
Country	:	US
Telephone Number	:	323-655-8220
Fax Number	:

Provider Business Practice Location Address
First Line	:	9105 W SUNSET BLVD
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90069-3106
Country	:	US
Telephone Number	:	323-655-8220
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT CEO
Name	:	DR. NILOUFAR GORMAN
Credential	:	LAC, MSOM
Telephone Number	:	323-655-8220

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	03/06/2008

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