Provider Demographics
NPI:1386280899
Name:WESTERN PACIFIC MED-CORP
Entity type:Organization
Organization Name:WESTERN PACIFIC MED-CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-956-3737
Mailing Address - Street 1:4544 SAN FERNANDO RD STE 202
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-5015
Mailing Address - Country:US
Mailing Address - Phone:818-956-3737
Mailing Address - Fax:818-543-6767
Practice Address - Street 1:26921 CROWN VALLEY PKWY STE 200
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6501
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:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone