MEDICARE: WESTERN HEALTH COMMUNITY CLINIC

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
1	261QM2800X	Methadone Clinic	19-035	CA

General Provider Information

NPI Number	:	1427204957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN HEALTH COMMUNITY CLINIC

Provider Business Mailing Address
First Line	:	1647 ANAHEIM ST
Second Line	:
City	:	HARBOR CITY
State	:	CA
Zip	:	90710-3213
Country	:	US
Telephone Number	:	310-534-5590
Fax Number	:	310-534-5591

Provider Business Practice Location Address
First Line	:	1647 ANAHEIM ST
Second Line	:
City	:	HARBOR CITY
State	:	CA
Zip	:	90710-3213
Country	:	US
Telephone Number	:	310-534-5590
Fax Number	:	310-534-5591

Authorized Official
Title or Position	:	DIRECTOR OF PROGRAMS
Name	:	MR. SIVAN S. WILSON
Credential	:
Telephone Number	:	310-534-5590

Provider Enumeration Date	:	08/15/2008
Last Update Date	:	08/15/2008

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