=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578869376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDENWEST MEDICAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2011
-----------------------------------------------------
Last Update Date | 01/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25422 TRABUCO RD STE 105-622
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-2791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-583-0937
-----------------------------------------------------
Fax | 949-583-0939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25422 TRABUCO RD STE 105-622
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-2791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-583-0937
-----------------------------------------------------
Fax | 949-583-0939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. JEANNIE AGEMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-583-0937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0901X
-----------------------------------------------------
Taxonomy Name | Public Health & General Preventive Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------