Healthcare Provider Details

I. General information

NPI: 1649902099
Provider Name (Legal Business Name): WP SUPPLY WEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2022
Last Update Date: 06/25/2022
Certification Date: 06/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6180 N HOLLYWOOD BLVD STE 102
LAS VEGAS NV
89115-1104
US

IV. Provider business mailing address

4640 ADMIRALTY WAY STE 500
MARINA DEL REY CA
90292-6636
US

V. Phone/Fax

Practice location:
  • Phone: 323-419-4609
  • Fax:
Mailing address:
  • Phone: 323-480-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER OTIKO
Title or Position: PRESIDENT
Credential: DPM
Phone: 818-836-2475