Provider Demographics
NPI:1386652881
Name:FOUR CORNERS MEDICAL SUPPLY
Entity Type:Organization
Organization Name:FOUR CORNERS MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOIBL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-565-4200
Mailing Address - Street 1:1108 N MILDRED RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321
Mailing Address - Country:US
Mailing Address - Phone:970-565-4200
Mailing Address - Fax:970-565-2786
Practice Address - Street 1:154 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3733
Practice Address - Country:US
Practice Address - Phone:435-678-2250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT841071727009Medicaid
UT5395360002Medicare NSC