Provider Demographics
NPI:1407991284
Name:MOUNT ROGERS COMMUNITY SERVICES
Entity Type:Organization
Organization Name:MOUNT ROGERS COMMUNITY SERVICES
Other - Org Name:MOUNT ROGERS COMMUNITY SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:REIMBURSEMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-223-3200
Mailing Address - Street 1:770 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1046
Mailing Address - Country:US
Mailing Address - Phone:276-223-3200
Mailing Address - Fax:276-223-0617
Practice Address - Street 1:770 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1046
Practice Address - Country:US
Practice Address - Phone:276-223-3200
Practice Address - Fax:276-223-0617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9061363Medicaid
VA9030140Medicaid