Provider Demographics
NPI:1740418680
Name:MISSION CENTER FOR LONGEVITY & AESTHETIC MEDICINE
Entity Type:Organization
Organization Name:MISSION CENTER FOR LONGEVITY & AESTHETIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF THE BOARD
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HEINRICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:949-364-2440
Mailing Address - Street 1:26730 CROWN VALLEY PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8000
Mailing Address - Country:US
Mailing Address - Phone:949-364-2440
Mailing Address - Fax:949-364-2778
Practice Address - Street 1:26730 CROWN VALLEY PKWY STE 250
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8000
Practice Address - Country:US
Practice Address - Phone:949-364-2440
Practice Address - Fax:949-364-2778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64307207R00000X
CAG69073207R00000X
CAG66486207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty