Basic Information
| Provider Information | |||||||||
| NPI: | 1821220955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN CPAP SUPPLY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 VALLEY VIEW DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SCOTTSBLUFF | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693611486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086333000 | ||||||||
| FaxNumber: | 3086333001 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 LARAMIE ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820011969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074264012 | ||||||||
| FaxNumber: | 3086333001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2009 | ||||||||
| LastUpdateDate: | 04/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | SCHULTZ | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3086333000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RPSGT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | WD-1197 WY | WY | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1053472191 | 05 | WY | MEDICAID |