Provider Demographics
NPI:1710996525
Name:YOUR SENIOR STORE, INC.
Entity Type:Organization
Organization Name:YOUR SENIOR STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-352-2440
Mailing Address - Street 1:1990 GREELEY MALL
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-8520
Mailing Address - Country:US
Mailing Address - Phone:970-352-2440
Mailing Address - Fax:
Practice Address - Street 1:1990 GREELEY MALL
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-8520
Practice Address - Country:US
Practice Address - Phone:970-352-2440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41387571Medicaid
CO5674650001Medicare ID - Type Unspecified