=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215958368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST COAST ORTHOTIC & PROSTHETIC SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 COFFEE RD STE 3
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-550-0100
-----------------------------------------------------
Fax | 209-550-0117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 COFFEE RD STE 3
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-550-0100
-----------------------------------------------------
Fax | 209-550-0117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | MR. DAVID R VERA SR.
-----------------------------------------------------
Credential | CO
-----------------------------------------------------
Telephone | 209-550-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225000000X
-----------------------------------------------------
Taxonomy Name | Orthotic Fitter
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------