Healthcare Provider Details

I. General information

NPI: 1679367635
Provider Name (Legal Business Name): MS. ALICE MARIE POWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 W WILLIAMS ST # 2
LONG BEACH CA
90810-3636
US

IV. Provider business mailing address

9203 MANDALE ST
BELLFLOWER CA
90706-2851
US

V. Phone/Fax

Practice location:
  • Phone: 562-743-2695
  • Fax:
Mailing address:
  • Phone: 562-292-9467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-VQIGR
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: