Provider Demographics
NPI:1023205853
Name:SOUTH COAST ORTHOPEDIC TECHNOLOGY
Entity Type:Organization
Organization Name:SOUTH COAST ORTHOPEDIC TECHNOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:PENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:508-998-7268
Mailing Address - Street 1:535 FAUNCE CORNER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:N DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-1242
Mailing Address - Country:US
Mailing Address - Phone:508-998-7268
Mailing Address - Fax:508-998-7267
Practice Address - Street 1:535 FAUNCE CORNER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:N DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1242
Practice Address - Country:US
Practice Address - Phone:508-998-7268
Practice Address - Fax:508-998-7267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1528866Medicaid
MA401154OtherBLUE CROSS BLUE SHIELD
MA811333OtherTUFTS
MA5386930001Medicare NSC