1124021092 NPI number — JACKSON PARISH AMBULANCE SERVICE DISTRICT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124021092 NPI number — JACKSON PARISH AMBULANCE SERVICE DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON PARISH AMBULANCE SERVICE DISTRICT
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:
Provider Other Organization Name Type Code:
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:
1124021092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 WATTS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71251-2053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-259-2891
Provider Business Mailing Address Fax Number:
318-259-2099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 WATTS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71251-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-259-2891
Provider Business Practice Location Address Fax Number:
318-259-2099
Provider Enumeration Date:
05/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WOLD
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
BRANDON
Authorized Official Title or Position:
EMS DIRECTOR
Authorized Official Telephone Number:
318-259-2877

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  9110021 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: F4632 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: P00634556 . This is a "RAILROAD MEDICARE (PALMETTO GBA)" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1550426 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".