=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629209127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE CREEK TRANSPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2009
-----------------------------------------------------
Last Update Date | 07/31/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7042 US HIGHWAY 212
-----------------------------------------------------
City | RED LODGE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59068-0962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-446-1722
-----------------------------------------------------
Fax | 406-466-1722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 962
-----------------------------------------------------
City | RED LODGE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59068-0962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-446-1722
-----------------------------------------------------
Fax | 406-466-1722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER BLUE CREEK TRANSPORT LLC
-----------------------------------------------------
Name | THOMAS BUSCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-446-1722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347B00000X
-----------------------------------------------------
Taxonomy Name | Bus
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------