Provider Demographics
NPI:1588998124
Name:PRAIRIE MEDICAL LLC
Entity type:Organization
Organization Name:PRAIRIE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEWCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CWCMS
Authorized Official - Phone:208-249-1185
Mailing Address - Street 1:4522 W MORGAN CREEK CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-3359
Mailing Address - Country:US
Mailing Address - Phone:208-249-1185
Mailing Address - Fax:208-938-4235
Practice Address - Street 1:1809 N LAKES PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1921
Practice Address - Country:US
Practice Address - Phone:208-249-1185
Practice Address - Fax:208-938-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDW82971332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6502510001Medicare NSC