Provider Demographics
NPI:1164410494
Name:SOUTHERN CALIFORNIA TRANSPLANTATION INSTITUTE
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA TRANSPLANTATION INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAKAN
Authorized Official - Middle Name:ERIK
Authorized Official - Last Name:WAHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-275-9000
Mailing Address - Street 1:4000 14TH ST
Mailing Address - Street 2:SUITE 512
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4019
Mailing Address - Country:US
Mailing Address - Phone:951-275-9000
Mailing Address - Fax:951-275-5262
Practice Address - Street 1:4000 14TH ST
Practice Address - Street 2:SUITE 512
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4083
Practice Address - Country:US
Practice Address - Phone:951-275-9000
Practice Address - Fax:951-275-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37140174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078850Medicaid
CAA28311Medicare UPIN
CAGR0078850Medicaid