Basic Information
| Provider Information | |||||||||
| NPI: | 1811175110 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN HEALTH RESOURCES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHOENIX HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ADVENTIST HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164060000 | ||||||||
| FaxNumber: | 9164062312 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 SAN HEDRIN CIR | ||||||||
| Address2: | |||||||||
| City: | WILLITS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954908753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074591818 | ||||||||
| FaxNumber: | 7074599298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2008 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | TRUDY | ||||||||
| AuthorizedOfficialMiddleName: | DELYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANGER | ||||||||
| AuthorizedOfficialTelephone: | 7074563230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 010000256 | CA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | HPC01649F | 05 | CA | MEDICAID |