1073661328 NPI number — DME HEALTH MANAGEMENT GROUP LLC

Table of content: (NPI 1073661328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073661328 NPI number — DME HEALTH MANAGEMENT GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DME HEALTH MANAGEMENT GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIBERTY CARE SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073661328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1641
Provider Second Line Business Mailing Address:
460 MAIN AVE. SOUTH SUITE C
Provider Business Mailing Address City Name:
TWIN FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-734-7730
Provider Business Mailing Address Fax Number:
208-735-8176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 MAIN AVE SOUTH
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-7730
Provider Business Practice Location Address Fax Number:
208-735-8176
Provider Enumeration Date:
01/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MORENO
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
MAJORITY MEMBER
Authorized Official Telephone Number:
208-734-7730

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 806769900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806815900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806875000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806857800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".