Provider Demographics
NPI:1003155474
Name:MEDICAL FIREFIGHTER INC
Entity Type:Organization
Organization Name:MEDICAL FIREFIGHTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERCL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:509-420-5125
Mailing Address - Street 1:PO BOX 2331
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-2331
Mailing Address - Country:US
Mailing Address - Phone:509-420-5125
Mailing Address - Fax:614-861-5537
Practice Address - Street 1:CORNER OF N12 & N7
Practice Address - Street 2:FD 2371 RED ROCK CIRCLE
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:509-420-5125
Practice Address - Fax:614-861-5537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP 60046454208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOP 60046454OtherWA LIC