Provider Demographics
NPI:1053705228
Name:BEVERLY HILLS WELLNESS PHYSICIANS CORP
Entity type:Organization
Organization Name:BEVERLY HILLS WELLNESS PHYSICIANS CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:LAUGESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-518-5980
Mailing Address - Street 1:7230 MEDICAL CENTER DRIVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307
Mailing Address - Country:US
Mailing Address - Phone:818-548-5980
Mailing Address - Fax:818-337-2049
Practice Address - Street 1:701 E 28TH ST STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2769
Practice Address - Country:US
Practice Address - Phone:562-426-2551
Practice Address - Fax:818-337-2049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT77740106H00000X
CAG44674207KA0200X, 207YX0602X, 2083P0901X, 208D00000X
CAG56249207QB0002X, 207W00000X
CAA063319207RN0300X
CAG284782082S0105X
CAPA11755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty