MEDICARE: WESTERN HEALTH COMMUNITY CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	G42264	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05D0548686	OTHER	CA	CLIA

General Provider Information

NPI Number	:	1134103930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN HEALTH COMMUNITY CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 6009
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90734-6009
Country	:	US
Telephone Number	:	310-938-4961
Fax Number	:	310-534-5591

Provider Business Practice Location Address
First Line	:	1647 W ANAHEIM ST
Second Line	:
City	:	HARBOR CITY
State	:	CA
Zip	:	90710-3213
Country	:	US
Telephone Number	:	310-534-5590
Fax Number	:	310-534-5591

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICK Q WILSON
Credential	:	PH.D.
Telephone Number	:	310-534-5590

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	08/08/2023

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Directions to “WESTERN HEALTH COMMUNITY CLINIC ” Practice Location

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