Provider Demographics
NPI:1396800975
Name:WACH
Entity type:Organization
Organization Name:WACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LVN 68WM6
Authorized Official - Prefix:MR
Authorized Official - First Name:LEZLIE
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-380-2621
Mailing Address - Street 1:1801 E RIMROCK RD APT P21 BOX114
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-5745
Mailing Address - Country:US
Mailing Address - Phone:661-717-8268
Mailing Address - Fax:
Practice Address - Street 1:1801 E RIMROCK RD APT P21 BOX114
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-5745
Practice Address - Country:US
Practice Address - Phone:661-717-8268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207529286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital