Provider Demographics
NPI:1447818240
Name:MOUNTAIN MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:MOUNTAIN MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:O
Authorized Official - Last Name:ROMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-307-5468
Mailing Address - Street 1:42545 RANGER CIRCLE WAY
Mailing Address - Street 2:
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-9636
Mailing Address - Country:US
Mailing Address - Phone:559-307-5468
Mailing Address - Fax:
Practice Address - Street 1:35344 HIGHWAY 41 STE D
Practice Address - Street 2:
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-8301
Practice Address - Country:US
Practice Address - Phone:559-307-5831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies