Provider Demographics
NPI:1740612134
Name:POWERSMD WELLNESS MEDICAL GROUP
Entity Type:Organization
Organization Name:POWERSMD WELLNESS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-843-0400
Mailing Address - Street 1:428 MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-8142
Mailing Address - Country:US
Mailing Address - Phone:714-843-0400
Mailing Address - Fax:714-969-4001
Practice Address - Street 1:428 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-8142
Practice Address - Country:US
Practice Address - Phone:714-843-0400
Practice Address - Fax:714-969-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15640207QA0401X, 208D00000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA119702OtherMEDICAL LICENSE
CAG15640OtherMEDICAL LICENSE