Healthcare Provider Details

I. General information

NPI: 1881033777
Provider Name (Legal Business Name): WESTERN PACIFIC RE-HAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9462 VAN NUYS BLVD
PANORAMA CITY CA
91402-1310
US

IV. Provider business mailing address

4544 SAN FERNANDO RD SUITE 202
GLENDALE CA
91204-1987
US

V. Phone/Fax

Practice location:
  • Phone: 818-891-8555
  • Fax:
Mailing address:
  • Phone: 818-956-3737
  • Fax: 818-543-6767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number19-121
License Number StateCA

VIII. Authorized Official

Name: MARK HICKMAN
Title or Position: CEO
Credential:
Phone: 818-956-3737