Provider Demographics
NPI:1003947953
Name:COUNTY OF TETON
Entity Type:Organization
Organization Name:COUNTY OF TETON
Other - Org Name:JACKSON HOLE FIRE EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:HL 'RUSTY'
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-572-4019
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0901
Mailing Address - Country:US
Mailing Address - Phone:402-572-4019
Mailing Address - Fax:402-965-8594
Practice Address - Street 1:40 E PEARL AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:402-572-4019
Practice Address - Fax:402-965-8594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF TETON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1133416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
10149OtherRAILROAD MEDICARE
WY1003947953OtherBLUE CROSS PROVIDER NUMBE
WY1003947953OtherBLUE CROSS PROVIDER NUMBE