Provider Demographics
NPI:1720279441
Name:WESTERN PACIFIC MED/CORP
Entity Type:Organization
Organization Name:WESTERN PACIFIC MED/CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-956-3737
Mailing Address - Street 1:4632 SAN FERNANDO RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1822
Mailing Address - Country:US
Mailing Address - Phone:818-956-3737
Mailing Address - Fax:818-543-6767
Practice Address - Street 1:4632 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1822
Practice Address - Country:US
Practice Address - Phone:818-956-3737
Practice Address - Fax:818-543-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHDC70063FMedicaid
CACMM70074FMedicaid
CAHDC70023FMedicaid
CAHDC70061FMedicaid
CACMM70045FMedicaid
CACMM70054FMedicaid
CACMM70208FMedicaid
CAHDC70062FMedicaid
CACMM70047FMedicaid
CAHDC70028FMedicaid