Provider Demographics
NPI:1497939193
Name:LOS ANGELES COUNTY - WIDNEY MTU
Entity Type:Organization
Organization Name:LOS ANGELES COUNTY - WIDNEY MTU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MPH
Authorized Official - Phone:626-569-6001
Mailing Address - Street 1:9320 TELSTAR AVE STE 226
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2816
Mailing Address - Country:US
Mailing Address - Phone:800-288-4584
Mailing Address - Fax:626-569-6480
Practice Address - Street 1:2302 S GRAMERCY PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-1323
Practice Address - Country:US
Practice Address - Phone:323-731-8442
Practice Address - Fax:323-733-2486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACCS00135FMedicaid