Basic Information
Provider Information | |||||||||
NPI: | 1336289297 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VASE FUNERAL HOME | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VASE EMERGENCY MEDICAL SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2400 | ||||||||
Address2: |   | ||||||||
City: | ROCK SPRINGS | ||||||||
State: | WY | ||||||||
PostalCode: | 829022400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8668834336 | ||||||||
FaxNumber: | 3073624339 | ||||||||
Practice Location | |||||||||
Address1: | 168 ELK ST | ||||||||
Address2: |   | ||||||||
City: | ROCK SPRINGS | ||||||||
State: | WY | ||||||||
PostalCode: | 829015241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073625607 | ||||||||
FaxNumber: | 3073622750 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2007 | ||||||||
LastUpdateDate: | 09/09/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VASE | ||||||||
AuthorizedOfficialFirstName: | KIM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3073625607 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 68 | WY | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 112443900 | 05 | WY |   | MEDICAID | 04796001 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER |