Provider Demographics
NPI:1811229214
Name:SACRED MOUNTAIN NON-MEDICAL TRANSPORT
Entity Type:Organization
Organization Name:SACRED MOUNTAIN NON-MEDICAL TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-871-4997
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:ST MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-0315
Mailing Address - Country:US
Mailing Address - Phone:928-871-4997
Mailing Address - Fax:928-871-5008
Practice Address - Street 1:HWY 264 RT 12 SPACE 4
Practice Address - Street 2:
Practice Address - City:WINDOWROCK
Practice Address - State:AZ
Practice Address - Zip Code:86515
Practice Address - Country:US
Practice Address - Phone:928-871-4997
Practice Address - Fax:928-871-5008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)