Provider Demographics
NPI:1134131170
Name:ADVANCED MOBILITY
Entity Type:Organization
Organization Name:ADVANCED MOBILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:COLTER
Authorized Official - Middle Name:DAR
Authorized Official - Last Name:KIRKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-478-6554
Mailing Address - Street 1:450 E DAY ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-7204
Mailing Address - Country:US
Mailing Address - Phone:208-478-6554
Mailing Address - Fax:208-478-6551
Practice Address - Street 1:450 E DAY ST
Practice Address - Street 2:SUITE F
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-7204
Practice Address - Country:US
Practice Address - Phone:208-478-6554
Practice Address - Fax:208-478-6551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806280600Medicaid
ID806280600Medicaid