Basic Information
| Provider Information | |||||||||
| NPI: | 1851501233 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST COUNTY MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26460 SUMMIT CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913502991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612546630 | ||||||||
| FaxNumber: | 6612546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E MARKET STREET | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908055924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624284222 | ||||||||
| FaxNumber: | 5624280372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | PRAMESH | ||||||||
| AuthorizedOfficialMiddleName: | PRAKASH | ||||||||
| AuthorizedOfficialTitleorPosition: | SR V P | ||||||||
| AuthorizedOfficialTelephone: | 6612546630 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 19-037 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 1946 | 01 | CA | ADPA | OTHER | 19-037 | 01 | CA | STATE NTP LICENSE | OTHER |