Basic Information
| Provider Information | |||||||||
| NPI: | 1518089499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST RIVER HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | WEST RIVER AMBULANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 HIGHWAY 12 | ||||||||
| Address2: | |||||||||
| City: | HETTINGER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586397530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015674561 | ||||||||
| FaxNumber: | 7015676361 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 HIGHWAY 12 | ||||||||
| Address2: | |||||||||
| City: | HETTINGER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586397530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015674561 | ||||||||
| FaxNumber: | 7015676361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7015676184 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST RIVER HEALTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 50783 | 05 | ND | MEDICAID | 011882 | 01 | ND | BCBS OF NORTH DAKOTA | OTHER | 9010550 | 05 | SD | MEDICAID |