Provider Demographics
NPI:1619341567
Name:WEST COAST ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:WEST COAST ORTHOTICS AND PROSTHETICS
Other - Org Name:WEST COAST O & P
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RYDER
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:231-894-0045
Mailing Address - Street 1:4915 STANTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:MI
Mailing Address - Zip Code:49437-1039
Mailing Address - Country:US
Mailing Address - Phone:231-894-0045
Mailing Address - Fax:
Practice Address - Street 1:4915 STANTON BLVD
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MI
Practice Address - Zip Code:49437-1039
Practice Address - Country:US
Practice Address - Phone:231-894-0045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACO2476335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier