Basic Information
| Provider Information | |||||||||
| NPI: | 1710051032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ATG-WCI INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NUMOTION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2070 LITTLE HILLS EXPY | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633013708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144477500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3137 TOMAHAWK DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952052472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094671173 | ||||||||
| FaxNumber: | 2094674549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING AND LICENSURE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3144477515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BC3200X | 101198 | CA | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | DME00965G | 05 | CA | MEDICAID | ZZZ06338Z | 01 | CA | BLUE SHIELD | OTHER | -3388156 | 05 | NV | MEDICAID | 364400270 | 01 | WISCONSIN PHYSICIANS SERV | OTHER | DME02889F | 05 | CA | MEDICAID |