1467640011 NPI number — WILSHIRE ONCOLOGY MEDICAL GROUP, INC.

Table of content: (NPI 1467640011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467640011 NPI number — WILSHIRE ONCOLOGY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILSHIRE ONCOLOGY MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467640011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1502 ARROW HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA VERNE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91750-5318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-593-4333
Provider Business Mailing Address Fax Number:
909-593-5588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 S SUNSET AVE
Provider Second Line Business Practice Location Address:
303
Provider Business Practice Location Address City Name:
WEST COVINA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91790-3961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-856-5858
Provider Business Practice Location Address Fax Number:
909-593-5588
Provider Enumeration Date:
10/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOSSERMAN
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
DIANA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-593-4333

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ83087Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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