MEDICARE: PLASTIC AND RECONSTRUCTIVE CARE, LLC

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
2	2086S0122X	Plastic and Reconstructive Surgery Physician

General Provider Information

NPI Number	:	1962979484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLASTIC AND RECONSTRUCTIVE CARE, LLC

Provider Business Mailing Address
First Line	:	3505 ALMA AVE
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-3330
Country	:	US
Telephone Number	:	310-801-6741
Fax Number	:

Provider Business Practice Location Address
First Line	:	9735 WILSHIRE BLVD PH
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90212-2104
Country	:	US
Telephone Number	:	310-860-8915
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. MIKE ROMAGNOLI
Credential	:
Telephone Number	:	310-801-6741

Provider Enumeration Date	:	11/02/2018
Last Update Date	:	03/05/2019

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