Healthcare Provider Details

I. General information

NPI: 1386789311
Provider Name (Legal Business Name): WEST COVINA MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W WEST COVINA PKWY
WEST COVINA CA
91790-2707
US

IV. Provider business mailing address

777 FLOWER ST STE A
GLENDALE CA
91201-3000
US

V. Phone/Fax

Practice location:
  • Phone: 626-960-8614
  • Fax: 626-960-9177
Mailing address:
  • Phone: 818-637-2000
  • Fax: 818-242-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KERRY WEINER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-637-2000