Provider Demographics
NPI:1972570174
Name:MOUNTAIN ANESTHESIA CARE INC
Entity type:Organization
Organization Name:MOUNTAIN ANESTHESIA CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO MOUNTAIN ANESTHESIA CARE INC
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ADOLF
Authorized Official - Last Name:WILD
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:909-336-3651
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352
Mailing Address - Country:US
Mailing Address - Phone:316-281-3700
Mailing Address - Fax:316-282-4322
Practice Address - Street 1:29101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352
Practice Address - Country:US
Practice Address - Phone:909-336-3651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty