1790931061 NPI number — AMBULANCE SERVICES OF TOOELE, LLC

Table of content: (NPI 1790931061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790931061 NPI number — AMBULANCE SERVICES OF TOOELE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMBULANCE SERVICES OF TOOELE, LLC
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:
1790931061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2055 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOOELE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84074-9819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-843-8745
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
153 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOOELE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84074-2127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-884-0913
Provider Business Practice Location Address Fax Number:
435-884-6208
Provider Enumeration Date:
08/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FEY
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DIRECTOR, CLINIC REVENUE CYCLE
Authorized Official Telephone Number:
615-221-3641

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  2006223 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 23200000000001 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1790931061 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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