Healthcare Provider Details

I. General information

NPI: 1952172199
Provider Name (Legal Business Name): MARK POWERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 MASSACHUSETTS ST
GARY IN
46402-1314
US

IV. Provider business mailing address

7908 MAPLE AVE
GARY IN
46403-1324
US

V. Phone/Fax

Practice location:
  • Phone: 219-678-0255
  • Fax:
Mailing address:
  • Phone: 219-678-0255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347D00000X
TaxonomyTrain
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: