Basic Information
| Provider Information | |||||||||
| NPI: | 1588648380 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN HEALTH RESOURCES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTERN HEALTH HOMECARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 DOUGLAS BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167802480 | ||||||||
| FaxNumber: | 9167812460 | ||||||||
| Practice Location | |||||||||
| Address1: | 591 CAMINO DE LA REINA | ||||||||
| Address2: | SUITE 1010 A | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921083102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192936800 | ||||||||
| FaxNumber: | 6196923119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WIEDEMANN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9167802480 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 080000085 | CA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | HHA07114I | 05 | CA | MEDICAID |