Provider Demographics
NPI:1295573384
Name:INTIMATE MOMENTS ENTERTAINMENT LLC
Entity type:Organization
Organization Name:INTIMATE MOMENTS ENTERTAINMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-210-2149
Mailing Address - Street 1:320 4TH ST NW STE 200222
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5152
Mailing Address - Country:US
Mailing Address - Phone:507-210-2149
Mailing Address - Fax:
Practice Address - Street 1:320 4TH ST NW STE 200222
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5152
Practice Address - Country:US
Practice Address - Phone:507-210-2149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)