Healthcare Provider Details

I. General information

NPI: 1235721572
Provider Name (Legal Business Name): MOUNTAIN CARE MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 S MAIN ST STE D
SNOWFLAKE AZ
85937-5285
US

IV. Provider business mailing address

91 S MAIN ST STE D
SNOWFLAKE AZ
85937-5285
US

V. Phone/Fax

Practice location:
  • Phone: 928-457-2500
  • Fax: 928-457-0404
Mailing address:
  • Phone: 928-457-2500
  • Fax: 928-457-0404

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 Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: BRANDON JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 928-457-2500