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NPI Code Detail

MEDICARE: WESTERN PACIFIC MED-CORP

MEDICARE: WESTERN PACIFIC MED-CORP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM2800XMethadone Clinic19-139CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11902OTHERCADRUG MEDICAL PROVIDER
2HDC70063FOTHERCAMEDICAL PROVIDER

General Provider Information

NPI Number : 1124160080
Entity Type Code : Organization
Provider Name (Legal Business Name) : WESTERN PACIFIC MED-CORP
Provider Business Mailing Address
First Line : 4544 SAN FERNANDO RD
Second Line : SUITE 202
City : GLENDALE
State : CA
Zip : 91204-1987
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4838 LAUREL CANYON BLVD
Second Line :
City : NORTH HOLLYWOOD
State : CA
Zip : 91607-3717
Country : US
Telephone Number : 818-956-3737
Fax Number :
Authorized Official
Title or Position : C.E.O.
Name : MARK HICKMAN
Credential :
Telephone Number : 818-956-3737
Provider Enumeration Date : 02/13/2007
Last Update Date : 02/06/2020

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Directions to “WESTERN PACIFIC MED-CORP ” Practice Location

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