Healthcare Provider Details

I. General information

NPI: 1760965081
Provider Name (Legal Business Name): W.P.R. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/26/2020
Certification Date: 09/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2733 COUNTRY CLUB BLVD APT 87
STOCKTON CA
95204-3975
US

IV. Provider business mailing address

9919 MARQUAND DR
BURKE VA
22015-3808
US

V. Phone/Fax

Practice location:
  • Phone: 209-276-8892
  • Fax:
Mailing address:
  • Phone: 206-201-9454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State

VIII. Authorized Official

Name: ANDREW JOHNSON
Title or Position: PRESIDENT
Credential:
Phone: 209-276-8892