1164911749 NPI number — ROCKY MOUNTAIN HOLDINGS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164911749 NPI number — ROCKY MOUNTAIN HOLDINGS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCKY MOUNTAIN HOLDINGS, 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:
LIFENET OF NEW YORK
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:
1164911749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 713362
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45271-3362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-636-4438
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
199 RIVER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIDNEY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13838-0056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-563-8116
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KECK
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
303-792-7400

Provider Taxonomy Codes

  • Taxonomy code: 3416A0800X , with the licence number:  34597 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01653745 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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