Provider Demographics
NPI:1407901739
Name:LOYALSOCK MOBILITY SERVICES LLC
Entity Type:Organization
Organization Name:LOYALSOCK MOBILITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-326-3431
Mailing Address - Street 1:607 PINE ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-5014
Mailing Address - Country:US
Mailing Address - Phone:570-326-3431
Mailing Address - Fax:570-505-1389
Practice Address - Street 1:607 PINE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-5014
Practice Address - Country:US
Practice Address - Phone:570-326-3431
Practice Address - Fax:570-505-1389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026606940001Medicaid
PA681906OtherADVANTRA FREEDOM
PA681906OtherADVANTRA FREEDOM