Healthcare Provider Details

I. General information

NPI: 1841616026
Provider Name (Legal Business Name): GOLDEN WEST MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S. ANAHEIM BLVD. SUITE 200
ANAHEIM CA
92805-5802
US

IV. Provider business mailing address

1000 S. ANAHEIM BLVD. SUITE 200
ANAHEIM CA
92805-5802
US

V. Phone/Fax

Practice location:
  • Phone: 714-634-4884
  • Fax: 714-635-5389
Mailing address:
  • Phone: 714-634-4884
  • Fax: 714-635-5389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number42656
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number42656
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number68972
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number42656
License Number StateCA

VIII. Authorized Official

Name: DR. BRIAN CAPELOTO
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 714-634-4884