Healthcare Provider Details

I. General information

NPI: 1740612134
Provider Name (Legal Business Name): POWERSMD WELLNESS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 MAIN ST SUITE 101
HUNTINGTON BEACH CA
92648-8142
US

IV. Provider business mailing address

428 MAIN ST SUITE 101
HUNTINGTON BEACH CA
92648-8142
US

V. Phone/Fax

Practice location:
  • Phone: 714-843-0400
  • Fax: 714-969-4001
Mailing address:
  • Phone: 714-843-0400
  • Fax: 714-969-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG15640
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberG15640
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberG15640
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG15640
License Number StateCA

VIII. Authorized Official

Name: DR. THOMAS POWERS
Title or Position: OWNER
Credential: MD
Phone: 714-843-0400