Provider Demographics
NPI:1093919615
Name:PACIFIC WEST COAST HEALTH MEDICAL THERAPY CENTER INC.
Entity type:Organization
Organization Name:PACIFIC WEST COAST HEALTH MEDICAL THERAPY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DESIGNATED CONTACT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-428-8065
Mailing Address - Street 1:1441 WESTWOOD BLVD
Mailing Address - Street 2:#E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11540 SANTA MONICA BLVD
Practice Address - Street 2:201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7905
Practice Address - Country:US
Practice Address - Phone:310-428-8065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty