Basic Information
| Provider Information | |||||||||
| NPI: | 1720279441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN PACIFIC MED/CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4632 SAN FERNANDO RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912041822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189563737 | ||||||||
| FaxNumber: | 8185436767 | ||||||||
| Practice Location | |||||||||
| Address1: | 4632 SAN FERNANDO RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912041822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189563737 | ||||||||
| FaxNumber: | 8185436767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 09/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | HICKMAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8189563737 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | HDC70063F | 05 | CA | MEDICAID | CMM70074F | 05 | CA | MEDICAID | HDC70023F | 05 | CA | MEDICAID | HDC70061F | 05 | CA | MEDICAID | CMM70045F | 05 | CA | MEDICAID | CMM70054F | 05 | CA | MEDICAID | CMM70208F | 05 | CA | MEDICAID | HDC70062F | 05 | CA | MEDICAID | CMM70047F | 05 | CA | MEDICAID | HDC70028F | 05 | CA | MEDICAID |