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General NPI Number Information
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NPI Number | 1164410494
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Entity Type | Organization
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Legal Business Name | SOUTHERN CALIFORNIA TRANSPLANTATION INSTITUTE
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Dates
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Enumeration Date | 10/11/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4000 14TH ST SUITE 512
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City | RIVERSIDE
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State | CA
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Zip | 92501-4083
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Country | US
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Telephone | 951-275-9000
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Fax | 951-275-5262
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Provider Business Mailing Address
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Address Line | 4000 14TH ST SUITE 512
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City | RIVERSIDE
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State | CA
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Zip | 92501-4019
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Country | US
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Telephone | 951-275-9000
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Fax | 951-275-5262
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/PRESIDENT
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Name | DR. HAKAN ERIK WAHLSTROM
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Credential | M.D.
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Telephone | 951-275-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A37140
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License Number State | CA
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