Basic Information
Provider Information | |||||||||
NPI: | 1568640860 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTERN HEALTH RESOURCES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVENTIST HEALTH HOME CARE AND HOSPICE SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2100 DOUGLAS BLVD | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956613804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9167802480 | ||||||||
FaxNumber: | 9167812460 | ||||||||
Practice Location | |||||||||
Address1: | 460 KINGS COUNTY DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | HANFORD | ||||||||
State: | CA | ||||||||
PostalCode: | 932305953 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5595853425 | ||||||||
FaxNumber: | 5595853420 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2008 | ||||||||
LastUpdateDate: | 11/16/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WIEDEMANN | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 9167802480 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 040000346 | CA | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | HPC01670F | 05 | CA |   | MEDICAID |