Provider Demographics
NPI:1245742097
Name:POCATELLO LIMOUSINE LLP
Entity Type:Organization
Organization Name:POCATELLO LIMOUSINE LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-589-3937
Mailing Address - Street 1:717 W ELDREDGE RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5620
Mailing Address - Country:US
Mailing Address - Phone:208-480-1250
Mailing Address - Fax:
Practice Address - Street 1:717 W ELDREDGE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5620
Practice Address - Country:US
Practice Address - Phone:208-480-1250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID343800000X, 343900000X, 347B00000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347B00000XTransportation ServicesBus
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922463751Medicaid