Basic Information
| Provider Information | |||||||||
| NPI: | 1285663468 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN HEALTH RESOURCES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVENTIST HEALTH PERSONAL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 DOUGLAS BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167814772 | ||||||||
| FaxNumber: | 9167743341 | ||||||||
| Practice Location | |||||||||
| Address1: | 5835 NE 122ND AVE | ||||||||
| Address2: | SUITE 155 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972301057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032516303 | ||||||||
| FaxNumber: | 5032516265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WIEDEMANN | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 9167814772 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 394343 | OR | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 509482 | 05 | OR | MEDICAID |