Provider Demographics
NPI:1841261955
Name:WEST COAST ORTHOTIC & PROSTHETIC SER INC
Entity type:Organization
Organization Name:WEST COAST ORTHOTIC & PROSTHETIC SER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:VERA
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:209-333-1148
Mailing Address - Street 1:400 E KETTLEMAN LN
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5962
Mailing Address - Country:US
Mailing Address - Phone:209-333-1148
Mailing Address - Fax:209-333-0624
Practice Address - Street 1:400 E KETTLEMAN LN
Practice Address - Street 2:SUITE 1
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5962
Practice Address - Country:US
Practice Address - Phone:209-333-1148
Practice Address - Fax:209-333-0624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000100Medicaid
CA0212880003Medicare ID - Type Unspecified