Organization
WESTERN PACIFIC RE-HAB
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK HICKMAN (CEO)
(818) 956-3737
Entity
Organization
Contact information
Practice address
9462 VAN NUYS BLVD, PANORAMA CITY, CA 91402-1310
(818) 891-8555
Mailing address
4544 SAN FERNANDO RD, SUITE 202, GLENDALE, CA 91204-1987
(818) 956-3737
(818) 543-6767
Taxonomy
Speciality
Code
Description
License number
State
261QM2800X
Methadone Clinic
Primary
19-121
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
7000
CALIFORNIA DRUG MEDI-CAL
CA
Enumeration date
06/24/2013
Last updated
01/23/2020
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