# PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1023428521
- **Legal business name:** PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.
- **Authorized official:** DR. LYNN J. GOODLOE M.D. (MEDICAL DIRECTOR)
- **Authorized official phone:** (818) 518-5980

## Contact information

- **Practice address:** 6310 SAN VICENTE BLVD, SUITE 220, LOS ANGELES, CA 90048-5426
- **Practice address phone:** (818) 518-5980
- **Practice address fax:** (818) 337-2049
- **Mailing address:** 2980 N BEVERLY GLEN CIR, SUITE 100, LOS ANGELES, CA 90077-1726
- **Mailing address phone:** (310) 943-4180
- **Mailing address fax:** (888) 431-8819

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332900000X | Non-Pharmacy Dispensing Site | G44674 | CA | Yes |

## Other

- **Enumeration date:** 05/06/2014
- **Last updated:** 10/05/2015