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General NPI Number Information
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NPI Number | 1295994291
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Entity Type | Organization
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Legal Business Name | COPPER CREEK MEDICAL INC
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Dates
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Enumeration Date | 06/04/2008
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Last Update Date | 04/06/2009
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Provider Practice Location Address
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Address Line | 2005 IRONWOOD PKWY SUITE 130
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2465
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Country | US
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Telephone | 208-667-3203
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Fax | 208-667-3110
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Provider Business Mailing Address
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Address Line | 2005 IRONWOOD PKWY 130
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2465
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Country | US
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Telephone | 208-667-3203
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Fax | 208-667-3110
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Authorized Official
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Title or Position | PRESIDENT
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Name | ALFRED A TALL
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Credential | RRT, RPSGT
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Telephone | 206-331-1675
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number | LRT443
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License Number State | ID
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