Basic Information
| Provider Information | |||||||||
| NPI: | 1346225133 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN HEALTH RESOURCES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVENTIST HEALTH HOME MEDICAL EQUIPMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 DOUGLAS BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167814771 | ||||||||
| FaxNumber: | 9167743341 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 TROUSDALE DR | ||||||||
| Address2: | SUITE #A | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919101079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194264662 | ||||||||
| FaxNumber: | 6194264362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 07/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | WIEDEMANN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9167814772 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | PHA437980 | 05 | CA | MEDICAID |