Healthcare Provider Details

I. General information

NPI: 1265869820
Provider Name (Legal Business Name): POWERSMD WELLNESS MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6552 BOLSA AVE SUITE H
HUNTINGTON BEACH CA
92647-2660
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 714-903-4570
  • Fax: 714-903-4571
Mailing address:
  • Phone: 714-843-0400
  • Fax: 714-969-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberG15640
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberG15640
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberG15640
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG15640
License Number StateCA

VIII. Authorized Official

Name: MR. THOMAS S. POWERS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-903-4570