Healthcare Provider Details

I. General information

NPI: 1669542205
Provider Name (Legal Business Name): WICORO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 N SUNSET AVE
WEST COVINA CA
91790-1244
US

IV. Provider business mailing address

919 N SUNSET AVE
WEST COVINA CA
91790-1244
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-4489
  • Fax: 626-337-4044
Mailing address:
  • Phone: 626-962-4489
  • Fax: 626-337-4044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number950000025
License Number StateCA

VIII. Authorized Official

Name: JUAN MORALES
Title or Position: OFFICE MANAGER
Credential:
Phone: 909-373-3766