Provider Demographics
NPI:1104834167
Name:DOCTORS HOSPITAL OF WEST COVINA, INC.
Entity Type:Organization
Organization Name:DOCTORS HOSPITAL OF WEST COVINA, INC.
Other - Org Name:DOCTORS HOSPITAL OF WEST COVINA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:WALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-338-8481
Mailing Address - Street 1:725 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2614
Mailing Address - Country:US
Mailing Address - Phone:626-338-8481
Mailing Address - Fax:626-960-9178
Practice Address - Street 1:725 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2614
Practice Address - Country:US
Practice Address - Phone:626-338-8481
Practice Address - Fax:626-960-9178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000188282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103925072Medicaid
CA050096Medicare Oscar/Certification
CAHSP40096HMedicaid
050096Medicare ID - Type Unspecified