MEDICARE: NEWPORT BEACH LASER AND PLASTIC SURGERY CENTRE

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	G47825	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G47825	OTHER	CA	STATE LICENSE NO.

General Provider Information

NPI Number	:	1972707123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEWPORT BEACH LASER AND PLASTIC SURGERY CENTRE

Provider Business Mailing Address
First Line	:	360 SAN MIGUEL DR STE 607
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7832
Country	:	US
Telephone Number	:	949-759-3284
Fax Number	:

Provider Business Practice Location Address
First Line	:	360 SAN MIGUEL DR STE 607
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7832
Country	:	US
Telephone Number	:	949-759-3284
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BORIS ACKERMAN
Credential	:	M.D.
Telephone Number	:	949-759-3284

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	08/22/2020

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