Provider Demographics
NPI:1023428521
Name:PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.
Entity type:Organization
Organization Name:PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOODLOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-518-5980
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-943-4180
Mailing Address - Fax:888-431-8819
Practice Address - Street 1:6310 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5426
Practice Address - Country:US
Practice Address - Phone:818-518-5980
Practice Address - Fax:818-337-2049
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-06
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44674332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site