Healthcare Provider Details

I. General information

NPI: 1457531824
Provider Name (Legal Business Name): WEST COAST ORTHOTIC LABS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 ENTERPRISE WAY
UPLAND CA
91786-1509
US

IV. Provider business mailing address

163 ENTERPRISE WAY
UPLAND CA
91786-1509
US

V. Phone/Fax

Practice location:
  • Phone: 909-946-5562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: PARK METHA
Title or Position: PRESIDENT
Credential:
Phone: 909-946-5562