=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447573621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAIDYN MED CARE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2010
-----------------------------------------------------
Last Update Date | 03/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1775 MCCULLOCH BLVD N
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-6549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-453-0696
-----------------------------------------------------
Fax | 928-453-0816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1840 MESQUITE AVE SUITE B
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-453-8500
-----------------------------------------------------
Fax | 928-453-3660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MANDEEP POWAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 928-453-0696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number | 24843
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------