1922079458 NPI number — PUERCO VALLEY AMBULANCE

Table of content: (NPI 1922079458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922079458 NPI number — PUERCO VALLEY AMBULANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUERCO VALLEY AMBULANCE
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:
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:
1922079458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 39
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDERS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86512-0039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-688-3616
Provider Business Mailing Address Fax Number:
928-688-2922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 S HWY 191
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDERS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-688-3616
Provider Business Practice Location Address Fax Number:
928-688-2922
Provider Enumeration Date:
02/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
TAMI
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT ADMIN CHIEF
Authorized Official Telephone Number:
928-688-3616

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  116 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 070558 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: R3451 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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