Provider Demographics
NPI:1427204957
Name:WESTERN HEALTH COMMUNITY CLINIC
Entity Type:Organization
Organization Name:WESTERN HEALTH COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROGRAMS
Authorized Official - Prefix:MR
Authorized Official - First Name:SIVAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-534-5590
Mailing Address - Street 1:1647 ANAHEIM ST
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3213
Mailing Address - Country:US
Mailing Address - Phone:310-534-5590
Mailing Address - Fax:310-534-5591
Practice Address - Street 1:1647 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:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19-035261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone