Provider Demographics
NPI:1134103930
Name:WESTERN HEALTH COMMUNITY CLINIC
Entity Type:Organization
Organization Name:WESTERN HEALTH COMMUNITY CLINIC
Other - Org Name:SMARTS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:Q
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-534-5590
Mailing Address - Street 1:PO BOX 6009
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90734-6009
Mailing Address - Country:US
Mailing Address - Phone:310-938-4961
Mailing Address - Fax:310-534-5591
Practice Address - Street 1:1647 W ANAHEIM ST
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3213
Practice Address - Country:US
Practice Address - Phone:310-534-5590
Practice Address - Fax:310-534-5591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0548686OtherCLIA
CABD614AMedicare PIN