Provider Demographics
NPI:1306362769
Name:MOUNTAIN MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:MOUNTAIN MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:REAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-327-0227
Mailing Address - Street 1:723 N 1890 W STE 38A
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1333
Mailing Address - Country:US
Mailing Address - Phone:435-327-0227
Mailing Address - Fax:877-492-2716
Practice Address - Street 1:6170 WOODSIDE EXECUTIVE CT
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-3820
Practice Address - Country:US
Practice Address - Phone:435-327-0227
Practice Address - Fax:877-492-2716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-17
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14834332B00000X
KY170014332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
617577000OtherU.S. DEPT OF LABOR OFFICE OF WORKERS' COMPENSATION PROGRAMS
622826800OtherU.S. DEPT OF LABOR OFFICE OF WORKERS' COMPENSATION PROGRAMS