Basic Information
| Provider Information | |||||||||
| NPI: | 1659849073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIMBOPRASETYO | ||||||||
| FirstName: | WURI | ||||||||
| MiddleName: | TRIHASTUTI | ||||||||
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| Credential: | RCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36853 BAY HILL DR | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922238015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612106227 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27300 IRIS AVE | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925554802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512430811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2018 | ||||||||
| LastUpdateDate: | 11/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 227900000X | 38700 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered |
No ID Information.