Healthcare Provider Details

I. General information

NPI: 1255998290
Provider Name (Legal Business Name): WEST COAST DME & SUPPLIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8322 CLAIREMONT MESA BLVD STE 105
SAN DIEGO CA
92111-1317
US

IV. Provider business mailing address

1835 CHICAGO AVE STE A
RIVERSIDE CA
92507-2309
US

V. Phone/Fax

Practice location:
  • Phone: 909-477-3117
  • Fax: 909-303-9244
Mailing address:
  • Phone: 909-477-3117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MICHAEL GREGORY WELLS
Title or Position: PRESIDENT
Credential: C.PED
Phone: 909-908-3920