Provider Demographics
NPI:1245685239
Name:NORTHWEST MEDICAL TRANSPORT LLC
Entity type:Organization
Organization Name:NORTHWEST MEDICAL TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-665-5671
Mailing Address - Street 1:101 E WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3329
Mailing Address - Country:US
Mailing Address - Phone:208-665-5671
Mailing Address - Fax:
Practice Address - Street 1:101 E WALNUT AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3329
Practice Address - Country:US
Practice Address - Phone:208-665-5671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM8077266Medicaid