Provider Demographics
NPI:1164429650
Name:MOUNTAIN AIR OXYGEN SERVICE, INC.
Entity Type:Organization
Organization Name:MOUNTAIN AIR OXYGEN SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KANEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-589-4112
Mailing Address - Street 1:2415 MULLINS AVE.
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-4264
Mailing Address - Country:US
Mailing Address - Phone:719-589-2573
Mailing Address - Fax:719-589-8891
Practice Address - Street 1:2415 MULLINS AVE.
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-4264
Practice Address - Country:US
Practice Address - Phone:719-589-2573
Practice Address - Fax:719-589-8891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO07150460001332BX2000X
332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08000648Medicaid
CO08000648Medicaid