Provider Demographics
NPI:1295994291
Name:COPPER CREEK MEDICAL INC
Entity type:Organization
Organization Name:COPPER CREEK MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:A
Authorized Official - Last Name:TALL
Authorized Official - Suffix:
Authorized Official - Credentials:RRT, RPSGT
Authorized Official - Phone:206-331-1675
Mailing Address - Street 1:2005 IRONWOOD PKWY
Mailing Address - Street 2:130
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2465
Mailing Address - Country:US
Mailing Address - Phone:208-667-3203
Mailing Address - Fax:208-667-3110
Practice Address - Street 1:2005 IRONWOOD PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2465
Practice Address - Country:US
Practice Address - Phone:208-667-3203
Practice Address - Fax:208-667-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLRT443332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies