Provider Demographics
NPI:1740695139
Name:HOLLYWOOD LIFESTYLE DERMAOTOGY
Entity type:Organization
Organization Name:HOLLYWOOD LIFESTYLE DERMAOTOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SABAT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:323-600-4156
Mailing Address - Street 1:7135 HOLLYWOOD BLVD
Mailing Address - Street 2:#306
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-3212
Mailing Address - Country:US
Mailing Address - Phone:323-301-3378
Mailing Address - Fax:213-256-0685
Practice Address - Street 1:7135 HOLLYWOOD BLVD
Practice Address - Street 2:#306
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-3212
Practice Address - Country:US
Practice Address - Phone:323-301-3378
Practice Address - Fax:213-256-0685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 8743261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI28568Medicare UPIN