Provider Demographics
NPI:1659381481
Name:EAGLE ROCK OXYGEN & MEDICAL
Entity Type:Organization
Organization Name:EAGLE ROCK OXYGEN & MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RT, CPFT
Authorized Official - Phone:208-535-8627
Mailing Address - Street 1:2114 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6475
Mailing Address - Country:US
Mailing Address - Phone:208-535-8627
Mailing Address - Fax:208-529-3368
Practice Address - Street 1:2114 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6475
Practice Address - Country:US
Practice Address - Phone:208-535-8627
Practice Address - Fax:208-529-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDME251332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8M785OtherBLUE CROSS OF IDAHO
ID000010154686OtherBLUE SHIELD OF IDAHO
ID807351700Medicaid
ID5556750001Medicare NSC