Provider Demographics
NPI:1396183547
Name:SHUTTLE RUIDOSO, LLC
Entity Type:Organization
Organization Name:SHUTTLE RUIDOSO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:CASON
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:575-257-1815
Mailing Address - Street 1:PO BOX 2030
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:NM
Mailing Address - Zip Code:88312-2030
Mailing Address - Country:US
Mailing Address - Phone:575-257-1815
Mailing Address - Fax:575-257-1816
Practice Address - Street 1:424 MECHEM DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6810
Practice Address - Country:US
Practice Address - Phone:575-257-1815
Practice Address - Fax:575-257-1816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNMPRC 54678343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM57550328Medicaid