NPIMap

Organization Active NPI

Western Pacific Med-Corp

  • Methadone Clinic
  • Fullerton, CA
National Provider Identifier
1750423620
Registry record updated Sep 28, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Methadone ClinicTaxonomy code 261QM2800X
License
30-11 Issued in CA
Legal business name
WESTERN PACIFIC MED-CORP
Practice address
218 E Commonwealth Ave
Fullerton, CA 92832-1911
Phone
(818) 956-3737
NPI assigned
Feb 13, 2007
Last updated
Sep 28, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 28, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mark Hickman
Title
C.E.O.
Phone
(818) 956-3737

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Methadone Clinic 261QM2800X 30-11 CA Primary

Addresses

Primary practice location

218 E Commonwealth Ave
Fullerton, CA 92832-1911

Mailing address

4544 San Fernando Rd
Suite 202
Glendale, CA 91204-1987

Other identifiers 2

IdentifierTypeStateIssuer
3099OtherCADRUG MEDICAL PROVIDER
CMM70208FOtherCAMEDICAL PROVIDER

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA
Opioid treatment program
Medicare-enrolled since Jan 1, 2020

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200214000625 CA Part B Supplier - Opioid Treatment Program (Otp) 5597738443 10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Mission Viejo, CA; Ventura, CA; Van Nuys, CA; Stanton, CA; Reseda, CA; Panorama City, CA; Norwalk, CA; North Hollywood, CA…

Other NPIs on the same Medicare enrollment 10

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D2144603Western Pacific Med Corp218 E Commonwealth Ave, Fullerton, CA 92832Certificate of waiverFeb 19, 2028

National Provider Directory

National Provider Directory
Tax ID family
Western Pacific Med-Corp19 organizations share this tax ID, including this one

Other organizations with this tax ID 18

Organizations that report the same tax identification number in the National Provider Directory.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1171324800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1443398400000",
    "number": "1750423620",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4544 SAN FERNANDO RD",
            "address_2": "SUITE 202",
            "city": "GLENDALE",
            "state": "CA",
            "postal_code": "912041987"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "218 E COMMONWEALTH AVE",
            "city": "FULLERTON",
            "state": "CA",
            "postal_code": "928321911",
            "telephone_number": "818-956-3737"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WESTERN PACIFIC MED-CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-13",
        "last_updated": "2015-09-28",
        "status": "A",
        "authorized_official_last_name": "HICKMAN",
        "authorized_official_first_name": "MARK",
        "authorized_official_title_or_position": "C.E.O.",
        "authorized_official_telephone_number": "818-956-3737"
    },
    "taxonomies": [
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": "CA",
            "license": "30-11",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DRUG MEDICAL PROVIDER",
            "identifier": "3099",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL PROVIDER",
            "identifier": "CMM70208F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fullerton, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 28, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.