Healthcare Provider Details

I. General information

NPI: 1205162013
Provider Name (Legal Business Name): POWERPLAY MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 WILSHIRE BOULEVARD
LOS ANGELES CA
90036
US

IV. Provider business mailing address

5800 WILSHIRE BOULEVARD
LOS ANGELES CA
90036
US

V. Phone/Fax

Practice location:
  • Phone: 310-289-8242
  • Fax: 310-289-8248
Mailing address:
  • Phone: 310-289-8242
  • Fax: 310-289-8248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberA53116
License Number StateCA

VIII. Authorized Official

Name: DR. LYDIE HAZAN
Title or Position: CEO/PRESIDENT
Credential: MD
Phone: 310-289-8242