Provider Demographics
NPI:1043483035
Name:WESTERN COMMUNITIES INTERNAL MEDICINE CORP
Entity type:Organization
Organization Name:WESTERN COMMUNITIES INTERNAL MEDICINE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:F
Authorized Official - Last Name:GUILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-385-7004
Mailing Address - Street 1:10115 FOREST HILL BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3105
Mailing Address - Country:US
Mailing Address - Phone:561-793-1117
Mailing Address - Fax:561-793-1762
Practice Address - Street 1:10115 FOREST HILL BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3105
Practice Address - Country:US
Practice Address - Phone:561-793-1117
Practice Address - Fax:561-793-1762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84093207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherFEDERAL TAX I.D.