Provider Demographics
NPI:1215366455
Name:SOUTHERN CALIFORNIA CENTER FOR ANTI AGING, INC.
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA CENTER FOR ANTI AGING, INC.
Other - Org Name:SOUTHERN CALIFORNIA CENTER FOR ANTI AGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GOLDSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-637-0232
Mailing Address - Street 1:23823 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5907
Mailing Address - Country:US
Mailing Address - Phone:424-247-4962
Mailing Address - Fax:
Practice Address - Street 1:23823 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5907
Practice Address - Country:US
Practice Address - Phone:424-247-4962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42196261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty