Basic Information
Provider Information | |||||||||
NPI: | 1912084716 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHENANDOAH AMBULANCE SERVICE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 PERSHING AVE | ||||||||
Address2: |   | ||||||||
City: | SHENANDOAH | ||||||||
State: | IA | ||||||||
PostalCode: | 516012355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122461230 | ||||||||
FaxNumber: | 7122467357 | ||||||||
Practice Location | |||||||||
Address1: | 300 PERSHING AVE | ||||||||
Address2: |   | ||||||||
City: | SHENANDOAH | ||||||||
State: | IA | ||||||||
PostalCode: | 516012355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122461230 | ||||||||
FaxNumber: | 7122467357 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 06/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SELLS | ||||||||
AuthorizedOfficialFirstName: | MATT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7122467100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 2730800 | IA | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 0228569 | 05 | IA |   | MEDICAID |