1043247679 NPI number — TIMBER LAKE AMBULANCE SERVICE INC

Table of content: (NPI 1043247679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043247679 NPI number — TIMBER LAKE AMBULANCE SERVICE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIMBER LAKE AMBULANCE SERVICE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TIMBER LAKE AMBULANCE SERVICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043247679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 641880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68164-7880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-572-4019
Provider Business Mailing Address Fax Number:
402-965-8594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIMBER LAKE
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-572-4019
Provider Business Practice Location Address Fax Number:
402-965-8594
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HERMES
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
402-572-4019

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  0243 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9017020 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0099213 . This is a "BLUE CROSS PROVIDER" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 590014108 . This is a "RR MEDICARE PROVIDER" identifier . This identifiers is of the category "OTHER".




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