Provider Demographics
NPI:1568054872
Name:SUMMIT SERVICES & SUPPLIES LLC
Entity Type:Organization
Organization Name:SUMMIT SERVICES & SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:EM
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-877-2993
Mailing Address - Street 1:PO BOX 1074
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-1074
Mailing Address - Country:US
Mailing Address - Phone:307-877-2993
Mailing Address - Fax:307-316-2910
Practice Address - Street 1:806 PINE AVE
Practice Address - Street 2:
Practice Address - City:KEMMERER
Practice Address - State:WY
Practice Address - Zip Code:83101-2900
Practice Address - Country:US
Practice Address - Phone:307-877-2993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2110ILGVFMedicaid
WY7911390001Medicaid