MEDICARE: WILSHIRE TREATMENT CENTER INC.

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	302F00000X	Exclusive Provider Organization	19133	CA

General Provider Information

NPI Number	:	1861674194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSHIRE TREATMENT CENTER INC.

Provider Business Mailing Address
First Line	:	11901 SANTA MONICA BLVD
Second Line	:	204
City	:	WEST LOS ANGELES
State	:	CA
Zip	:	90025-2767
Country	:	US
Telephone Number	:	310-268-2446
Fax Number	:	310-479-0861

Provider Business Practice Location Address
First Line	:	11901 SANTA MONICA BLVD
Second Line	:	204
City	:	WEST LOS ANGELES
State	:	CA
Zip	:	90025-2767
Country	:	US
Telephone Number	:	310-268-2446
Fax Number	:	310-479-0861

Authorized Official
Title or Position	:	COUNSELOR
Name	:	MS. SARAH TAYLOR
Credential	:	BA
Telephone Number	:	310-268-2446

Provider Enumeration Date	:	11/28/2007
Last Update Date	:	11/28/2007

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