MEDICARE: ROCKY MOUNTAIN HOLDINGS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416A0800X	Air Ambulance	29512	GA

General Provider Information

NPI Number	:	1861778052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKY MOUNTAIN HOLDINGS LLC

Provider Business Mailing Address
First Line	:	621 CARNEGIE DR
Second Line	:	STE 210
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3536
Country	:	US
Telephone Number	:	909-915-2303
Fax Number	:	402-952-2411

Provider Business Practice Location Address
First Line	:	BLDG 2485, JECELIN ST
Second Line	:
City	:	FORT BENNING
State	:	GA
Zip	:	31905
Country	:	US
Telephone Number	:	909-915-2303
Fax Number	:	402-952-2411

Authorized Official
Title or Position	:	VP OF PATIENT BUSINESS SERVICES
Name	:	MARK KEENE
Credential	:
Telephone Number	:	909-915-2301

Provider Enumeration Date	:	11/01/2011
Last Update Date	:	11/01/2011

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