Basic Information
| Provider Information | |||||||||
| NPI: | 1386280899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN PACIFIC MED-CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4544 SAN FERNANDO RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912045015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189563737 | ||||||||
| FaxNumber: | 8185436767 | ||||||||
| Practice Location | |||||||||
| Address1: | 26921 CROWN VALLEY PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189563737 | ||||||||
| FaxNumber: | 8185436767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2019 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | BLAKE | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8189563737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.