Provider Demographics
NPI:1730484304
Name:MOOSE MOUNTAIN SERVICES
Entity Type:Organization
Organization Name:MOOSE MOUNTAIN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-290-6726
Mailing Address - Street 1:3200 GREAT NORTHERN RD
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-9214
Mailing Address - Country:US
Mailing Address - Phone:770-375-8176
Mailing Address - Fax:
Practice Address - Street 1:3200 GREAT NORTHERN RD
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-9214
Practice Address - Country:US
Practice Address - Phone:770-375-8176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD144385343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID110120030Medicaid