Provider Demographics
NPI:1043337256
Name:CEDAR MOUNTAIN RESPIRATORY, INC.
Entity Type:Organization
Organization Name:CEDAR MOUNTAIN RESPIRATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:CRT
Authorized Official - Phone:208-762-4480
Mailing Address - Street 1:77 W COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9221
Mailing Address - Country:US
Mailing Address - Phone:208-762-4480
Mailing Address - Fax:208-762-4462
Practice Address - Street 1:77 W COMMERCE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9221
Practice Address - Country:US
Practice Address - Phone:208-762-4480
Practice Address - Fax:208-762-4462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5160400001Medicare NSC