Basic Information
| Provider Information | |||||||||
| NPI: | 1699854141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUDLAKE AMBULANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3362 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 EAST 1100 NORTH | ||||||||
| Address2: | |||||||||
| City: | TERRETON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087162369 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2087162369 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 7714 | ID | Y | Transportation Services | Ambulance | Land Transport |
No ID Information.