NPIMap

Organization Active NPI

Western Pacific Re-Hab

  • Methadone Clinic
  • Glendale, CA
National Provider Identifier
1770922650
Registry record updated Jan 23, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Methadone ClinicTaxonomy code 261QM2800X
License
19-125 Issued in CA
Legal business name
WESTERN PACIFIC RE-HAB
Practice address
4544 San Fernando Rd
Suite 201
Glendale, CA 91204-1987
Phone
(818) 240-8843
NPI assigned
Jun 24, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 23, 2020

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

Authorized official

Name
Mark Hickman
Title
Ceo
Phone
(818) 956-3737

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Methadone Clinic 261QM2800X 19-125 CA Primary

Addresses

Primary practice location

4544 San Fernando Rd
Suite 201
Glendale, CA 91204-1987

Mailing address

4544 San Fernando Rd
Suite 202
Glendale, CA 91204-1987
Phone (818) 956-3737

Other identifiers 1

IdentifierTypeStateIssuer
1949OtherCACALIFORNIA DRUG MEDI-CAL

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
O20200415001392 CA Part B Supplier - Opioid Treatment Program (Otp) 8022448059 6 other NPIs on this enrollment
Practice locations: Lancaster, CA; Reseda, CA; Panorama City, CA; Norwalk, CA; Glendale, CA; Fullerton, CA; Costa Mesa, CA

Other NPIs on the same Medicare enrollment 6

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

National Provider Directory

National Provider Directory
Tax ID family
Western Pacific Re-Hab7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

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

NPI Registry JSON

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

{
    "created_epoch": "1372032000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1579737600000",
    "number": "1770922650",
    "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",
            "telephone_number": "818-956-3737"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4544 SAN FERNANDO RD",
            "address_2": "SUITE 201",
            "city": "GLENDALE",
            "state": "CA",
            "postal_code": "912041987",
            "telephone_number": "818-240-8843"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WESTERN PACIFIC RE-HAB",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-06-24",
        "last_updated": "2020-01-23",
        "certification_date": "2020-01-23",
        "status": "A",
        "authorized_official_last_name": "HICKMAN",
        "authorized_official_first_name": "MARK",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "818-956-3737"
    },
    "taxonomies": [
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": "CA",
            "license": "19-125",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CALIFORNIA DRUG MEDI-CAL",
            "identifier": "1949",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Glendale, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 23, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.