Provider Demographics
NPI:1043423213
Name:WESTERN PACIFIC MED. CORP.
Entity Type:Organization
Organization Name:WESTERN PACIFIC MED. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-223-3869
Mailing Address - Street 1:174 S LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:955 E THOMPSON BLVD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001
Practice Address - Country:US
Practice Address - Phone:805-641-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-O0510041352302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization