Provider Demographics
NPI:1386923860
Name:BOOMERS MOBILITY SERVICES, INC
Entity type:Organization
Organization Name:BOOMERS MOBILITY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-266-9107
Mailing Address - Street 1:26672 RAY CT
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-6143
Mailing Address - Country:US
Mailing Address - Phone:855-266-9107
Mailing Address - Fax:
Practice Address - Street 1:26672 RAY CT
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-6143
Practice Address - Country:US
Practice Address - Phone:855-266-9107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
INBUSSARD224Medicare PIN