MEDICARE: WELLCARE MEDICAL CLINIC INC

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	A46552	CA

General Provider Information

NPI Number	:	1235575853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLCARE MEDICAL CLINIC INC

Provider Business Mailing Address
First Line	:	2990 E PACIFIC COAST HWY
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-1632
Country	:	US
Telephone Number	:	714-847-3322
Fax Number	:

Provider Business Practice Location Address
First Line	:	2990 E PACIFIC COAST HWY
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-1632
Country	:	US
Telephone Number	:	714-847-3322
Fax Number	:

Authorized Official
Title or Position	:	OFFICIER
Name	:	TRACY CHARLES
Credential	:	MD
Telephone Number	:	714-847-3322

Provider Enumeration Date	:	05/22/2013
Last Update Date	:	12/03/2013

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