Provider Demographics
NPI:1487741617
Name:ADVANCED MOBILITY REPAIR
Entity type:Organization
Organization Name:ADVANCED MOBILITY REPAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAZON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-219-1102
Mailing Address - Street 1:1411 NW LOUISIANA AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-1749
Mailing Address - Country:US
Mailing Address - Phone:360-219-1102
Mailing Address - Fax:360-237-0561
Practice Address - Street 1:21645 OREGON TRL
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9617
Practice Address - Country:US
Practice Address - Phone:360-219-1102
Practice Address - Fax:360-237-0561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602621899332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies