Provider Demographics
NPI:1942791611
Name:WESTERN U MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WESTERN U MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL COMPLIANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRENA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:AUTHORIZED OFFICIAL
Authorized Official - Phone:909-706-3871
Mailing Address - Street 1:795 E. SECOND STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766
Mailing Address - Country:US
Mailing Address - Phone:909-469-8332
Mailing Address - Fax:909-706-3785
Practice Address - Street 1:5909 SE 92ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-4642
Practice Address - Country:US
Practice Address - Phone:909-469-8534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty