Provider Demographics
NPI:1497850630
Name:WEST COAST ORTHOTIC AND PROSTHETIC
Entity Type:Organization
Organization Name:WEST COAST ORTHOTIC AND PROSTHETIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT CORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-845-8231
Mailing Address - Street 1:3215 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-3433
Mailing Address - Country:US
Mailing Address - Phone:209-942-4166
Mailing Address - Fax:209-942-4168
Practice Address - Street 1:3215 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-3433
Practice Address - Country:US
Practice Address - Phone:209-942-4166
Practice Address - Fax:209-942-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0212880004Medicare ID - Type Unspecified