MEDICARE: POWERPLAY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1004X	Pediatric Nutrition Registered Dietitian	A53116	CA

General Provider Information

NPI Number	:	1205162013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWERPLAY MD

Provider Business Mailing Address
First Line	:	5800 WILSHIRE BOULEVARD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036
Country	:	US
Telephone Number	:	310-289-8242
Fax Number	:	310-289-8248

Provider Business Practice Location Address
First Line	:	5800 WILSHIRE BOULEVARD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036
Country	:	US
Telephone Number	:	310-289-8242
Fax Number	:	310-289-8248

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	DR. LYDIE HAZAN
Credential	:	MD
Telephone Number	:	310-289-8242

Provider Enumeration Date	:	10/29/2009
Last Update Date	:	10/29/2009

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