=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205970480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCKY MOUNTAIN MOBILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3475 PINE TREE SQ STE A
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80909-6446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-473-4088
-----------------------------------------------------
Fax | 719-473-0397
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3475 PINE TREE SQ STE A
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80909-6446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-473-4088
-----------------------------------------------------
Fax | 719-473-0397
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. STAN PREDMORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-473-4088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 40359320000
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------