Basic Information
| Provider Information | |||||||||
| NPI: | 1427440049 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST COVINA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917902614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263388481 | ||||||||
| FaxNumber: | 6269609178 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917902614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263388481 | ||||||||
| FaxNumber: | 6269609178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2015 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROLLINS | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6263388481 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 1922016989 | CA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1922016989 | 01 | CA | NPI | OTHER |