Healthcare Provider Details

I. General information

NPI: 1235575853
Provider Name (Legal Business Name): WELLCARE MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 E PACIFIC COAST HWY
LONG BEACH CA
90804-1632
US

IV. Provider business mailing address

2990 E PACIFIC COAST HWY
LONG BEACH CA
90804-1632
US

V. Phone/Fax

Practice location:
  • Phone: 714-847-3322
  • Fax:
Mailing address:
  • Phone: 714-847-3322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA46552
License Number StateCA

VIII. Authorized Official

Name: TRACY CHARLES
Title or Position: OFFICIER
Credential: MD
Phone: 714-847-3322