Basic Information
Provider Information | |||||||||
NPI: | 1336361716 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CITY OF ORR | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ORR AMBULANCE SERVICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 55 | ||||||||
Address2: |   | ||||||||
City: | ORR | ||||||||
State: | MN | ||||||||
PostalCode: | 557710055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187573288 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3920 13TH AVE E | ||||||||
Address2: | SUITE 6 | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 557463675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2182637540 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 04/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KLAKOSKI | ||||||||
AuthorizedOfficialFirstName: | DIANA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AMBULANCE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2187573288 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X |   | MN | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 494S8C1 | 01 | MN | BLUE CROSS BLUE SHIELD MN | OTHER | 434397200 | 05 | MN |   | MEDICAID |