Provider Demographics
NPI:1447288436
Name:SACRED MOUNTAIN MEDICAL SERVICES INC
Entity type:Organization
Organization Name:SACRED MOUNTAIN MEDICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-283-8243
Mailing Address - Street 1:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-2290
Mailing Address - Country:US
Mailing Address - Phone:928-283-8243
Mailing Address - Fax:928-283-8237
Practice Address - Street 1:NP-39 MOENAVE RD/LOLMA ST
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-8243
Practice Address - Fax:928-283-8237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1273416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40953866Medicaid
CAXMTE06557Medicaid
AZ717077Medicaid
MS02876271Medicaid
AZAZ0152480OtherBLUE CROSS BLUE SHIELD
UT=========001Medicaid
CAXMTE06557Medicaid
NM40953866Medicaid