Provider Demographics
NPI:1942740857
Name:IDAHO TRANSPORT LLC
Entity Type:Organization
Organization Name:IDAHO TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:208-854-9076
Mailing Address - Street 1:9616 W BIENAPFL DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-4709
Mailing Address - Country:US
Mailing Address - Phone:208-854-9076
Mailing Address - Fax:
Practice Address - Street 1:9616 W BIENAPFL DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-4709
Practice Address - Country:US
Practice Address - Phone:208-854-9076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)