1669440392 NPI number — SOPERS MOBILITY AIDS LLC

Table of content: (NPI 1669440392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669440392 NPI number — SOPERS MOBILITY AIDS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOPERS MOBILITY AIDS 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:
Provider Other Organization Name Type Code:
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:
1669440392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2344
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-772-6474
Provider Business Mailing Address Fax Number:
208-772-6797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7392 N GOVERNMENT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALTON GARDENS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-8762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-772-6474
Provider Business Practice Location Address Fax Number:
208-772-6797
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SOPER
Authorized Official First Name:
GENEVA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER MANAGER
Authorized Official Telephone Number:
208-772-6474

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  59 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9054511 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 805521400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010137053 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805503900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8F728 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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