1255410841 NPI number — WILTON AMBULANCE SERVICE

Table of content: (NPI 1255410841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255410841 NPI number — WILTON AMBULANCE SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILTON AMBULANCE SERVICE
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:
6
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:
1255410841
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 974
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANDAN
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58554-0974
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-250-6361
Provider Business Mailing Address Fax Number:
701-255-7247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 DAKOTA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILTON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58579-0163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-734-6247
Provider Business Practice Location Address Fax Number:
701-734-6247
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOMONOSKE
Authorized Official First Name:
LEEANN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
AMBULANCE COORDINATOR
Authorized Official Telephone Number:
701-734-6247

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  133 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50397 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: WIL7618 . This is a "BLUE CROSS NORTH DAKOTA" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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