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General NPI Number Information
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NPI Number | 1730484304
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Entity Type | Organization
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Legal Business Name | MOOSE MOUNTAIN SERVICES
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Dates
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Enumeration Date | 01/12/2011
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Last Update Date | 01/12/2011
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Provider Practice Location Address
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Address Line | 3200 GREAT NORTHERN RD
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City | SANDPOINT
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State | ID
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Zip | 83864-9214
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Country | US
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Telephone | 770-375-8176
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Fax |
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Provider Business Mailing Address
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Address Line | 3200 GREAT NORTHERN RD
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City | SANDPOINT
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State | ID
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Zip | 83864-9214
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Country | US
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Telephone | 770-375-8176
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JESSE JACKSON
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Credential |
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Telephone | 208-290-6726
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number | D144385
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License Number State | ID
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