1619341567 NPI number — WEST COAST ORTHOTICS AND PROSTHETICS

Table of content: (NPI 1619341567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619341567 NPI number — WEST COAST ORTHOTICS AND PROSTHETICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST COAST ORTHOTICS AND PROSTHETICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WEST COAST O & P
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619341567
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4915 STANTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTAGUE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49437-1039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-894-0045
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4915 STANTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTAGUE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49437-1039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-894-0045
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RYDER
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
231-894-0045

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  CO2476 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com