Provider Demographics
NPI:1174661649
Name:MEDICAB
Entity type:Organization
Organization Name:MEDICAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:L
Authorized Official - Last Name:METIVIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-327-1510
Mailing Address - Street 1:PO BOX 1597
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-1597
Mailing Address - Country:US
Mailing Address - Phone:406-327-1510
Mailing Address - Fax:406-829-0482
Practice Address - Street 1:3301 PARK ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8762
Practice Address - Country:US
Practice Address - Phone:406-327-1510
Practice Address - Fax:406-829-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9199343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT540413Medicaid
MT520421Medicaid