Provider Demographics
NPI:1609273416
Name:MOUNTAIN STATES EMERGENCY MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:MOUNTAIN STATES EMERGENCY MEDICAL SERVICES, LLC
Other - Org Name:MOUNTAIN STATES EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-736-8950
Mailing Address - Street 1:1210 S PARKER RD
Mailing Address - Street 2:SUITE # 104
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-7555
Mailing Address - Country:US
Mailing Address - Phone:303-736-8950
Mailing Address - Fax:720-307-3008
Practice Address - Street 1:1210 S PARKER RD
Practice Address - Street 2:SUITE # 104
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-7555
Practice Address - Country:US
Practice Address - Phone:303-736-8950
Practice Address - Fax:720-307-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO341600000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
COBFN- 2015-BFN-000105OtherBUSINESS LICENSE - DENVER, CO
CO400069OtherMEDICARE PTAN
CO42434301Medicaid