Healthcare Provider Details

I. General information

NPI: 1245685239
Provider Name (Legal Business Name): NORTHWEST MEDICAL TRANSPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1726 W DEPO DR
HAYDEN ID
83835-8025
US

IV. Provider business mailing address

1726 W DEPO DR
HAYDEN ID
83835-8025
US

V. Phone/Fax

Practice location:
  • Phone: 208-665-5671
  • Fax:
Mailing address:
  • Phone: 208-665-5671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateID

VIII. Authorized Official

Name: JANIECE LAKE
Title or Position: OWNER
Credential:
Phone: 208-665-5671