1003947953 NPI number — COUNTY OF TETON

Table of content: (NPI 1003947953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003947953 NPI number — COUNTY OF TETON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF TETON
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:
JACKSON HOLE FIRE EMS
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:
1003947953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 901
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83001-0901
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:
40 E PEARL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83001
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:
03/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PALMER
Authorized Official First Name:
HL 'RUSTY'
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF
Authorized Official Telephone Number:
402-572-4019

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  113 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10149 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1003947953 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".