| Organization Name: | WILDERNESS SHORES SUPPLIES, LLC |
| NPI Number: | 1144545054 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SHIRLEY ANN MCMONAGLE (OWNER) |
| Mailing Address: | 25614 Lake Wilderness Ln Se Maple Valley |
| State: | WA US |
| Postal Code: | 980386019 |
| Phone Number: | 2069315284 |
| Fax Number: | 4254135116 |
| NPI Enumeration Date: | 04/02/2010 |
| NPI Last Update Date: | 04/02/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332BX2000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | Oxygen Equipment & Supplies |
| Taxonomy Definition: | |