Basic Information
| Provider Information | |||||||||
| NPI: | 1235272196 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN PACIFIC MED-CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4544 SAN FERNANDO RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912041987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189563737 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14332 VICTORY BLVD | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914011944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189563737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 09/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | HICKMAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 8189563737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 19-138 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | HDC70061F | 01 | CA | MEDICAL PROVIDER | OTHER | 6805 | 01 | CA | DRUG MEDICAL PROVIDER | OTHER |