MEDICARE: WEST COAST DME & SUPPLIES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	222Z00000X	Orthotist
2	224L00000X	Pedorthist
3	224P00000X	Prosthetist
4	225000000X	Orthotic Fitter
5	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1255998290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST COAST DME & SUPPLIES LLC

Provider Business Mailing Address
First Line	:	1835 CHICAGO AVE STE A
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-2309
Country	:	US
Telephone Number	:	909-477-3117
Fax Number	:

Provider Business Practice Location Address
First Line	:	8322 CLAIREMONT MESA BLVD STE 105
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-1317
Country	:	US
Telephone Number	:	909-477-3117
Fax Number	:	909-303-9244

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MICHAEL GREGORY WELLS
Credential	:	C.PED
Telephone Number	:	909-908-3920

Provider Enumeration Date	:	05/24/2019
Last Update Date	:	05/24/2019

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