Basic Information
| Provider Information | |||||||||
| NPI: | 1265525935 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN MEDICAL CENTER TRAUMA GRP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927813428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142891559 | ||||||||
| FaxNumber: | 7142890280 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 TUSTIN AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145303270 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 02/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | RICK | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7142891559 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0089430 | 05 | CA | MEDICAID |