Healthcare Provider Details

I. General information

NPI: 1073738563
Provider Name (Legal Business Name): WEST COAST ORTHOTIC AND PROSTHETIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 W KETTLEMAN LN SUITE A
LODI CA
95242-9287
US

IV. Provider business mailing address

693 HI TECH PKWY
OAKDALE CA
95361-9372
US

V. Phone/Fax

Practice location:
  • Phone: 209-333-1148
  • Fax: 209-333-0624
Mailing address:
  • Phone: 209-845-8231
  • Fax: 209-845-2883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER CREE
Title or Position: CONTRACT CORDINATOR
Credential:
Phone: 209-845-8231