1407969330 NPI number — CITY OF HORN LAKE

Table of content: (NPI 1407969330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407969330 NPI number — CITY OF HORN LAKE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF HORN LAKE
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:
CITY OF HORN 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:
1407969330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3101 GOODMAN RD W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HORN LAKE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38637-1173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-342-0839
Provider Business Mailing Address Fax Number:
662-280-1736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6363 HIGHWAY 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-781-1157
Provider Business Practice Location Address Fax Number:
662-781-7895
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LATIMER
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MAYOR
Authorized Official Telephone Number:
662-781-1157

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  1770 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08657221 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: ========= . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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