Provider Demographics
NPI:1023177110
Name:WEST COAST PROSTHETICS AND ORTHOTICS, LLC
Entity type:Organization
Organization Name:WEST COAST PROSTHETICS AND ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPO
Authorized Official - Phone:360-956-3333
Mailing Address - Street 1:PO BOX 1994
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-1994
Mailing Address - Country:US
Mailing Address - Phone:360-956-3333
Mailing Address - Fax:360-956-3339
Practice Address - Street 1:2102 CARRIAGE DR SW
Practice Address - Street 2:BLDG E
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502
Practice Address - Country:US
Practice Address - Phone:360-956-3333
Practice Address - Fax:360-956-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602115813335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9051483Medicaid
WA9051483Medicaid