Provider Demographics
NPI:1306203237
Name:REVERSE AGING CENTRE
Entity Type:Organization
Organization Name:REVERSE AGING CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:SAWAF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-273-1166
Mailing Address - Street 1:455 N ROXBURY DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 N ROXBURY DR
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5001
Practice Address - Country:US
Practice Address - Phone:310-273-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAS14226512086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty