1548520042 NPI number — SHOSHONE COUNTY EMS CORPORATION

Table of content: (NPI 1548520042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548520042 NPI number — SHOSHONE COUNTY EMS CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOSHONE COUNTY EMS CORPORATION
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:
1548520042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3510
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-3510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-394-7010
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 OREGON ST
Provider Second Line Business Practice Location Address:
SUITE Q
Provider Business Practice Location Address City Name:
KELLOGG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83837-5018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-446-4822
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HOLSTEIN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF OFFICER
Authorized Official Telephone Number:
208-446-4822

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  7807 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1548520042 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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