Healthcare Provider Details

I. General information

NPI: 1457578288
Provider Name (Legal Business Name): WESLEY WILLIAM MCCORMICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 FAIR OAKS AVE 300
SOUTH PASADENA CA
91030-2630
US

IV. Provider business mailing address

533 HIGHLAND ST
PASADENA CA
91104-1118
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-831-6726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: