Basic Information
| Provider Information | |||||||||
| NPI: | 1205827813 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAGIC VALLEY PARAMEDICS L L C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2777 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837012777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087065000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 285 MARTIN ST | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833014532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087372298 | ||||||||
| FaxNumber: | 2087323065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE, CFO | ||||||||
| AuthorizedOfficialTelephone: | 2083812520 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 8520 | ID | N | Transportation Services | Ambulance | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 000010149121 | 01 | ID | BS ID PROVIDER NUMBER | OTHER | 807075100 | 05 | ID | MEDICAID | E1144 | 01 | ID | BC ID PROVIDER NUMBER | OTHER |