Provider Demographics
NPI:1023214293
Name:TEKOA COMMUNITY AMBULANCE
Entity Type:Organization
Organization Name:TEKOA COMMUNITY AMBULANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-284-2246
Mailing Address - Street 1:S. 226 RAMSEY ST.
Mailing Address - Street 2:PO BOX 597
Mailing Address - City:TEKOA
Mailing Address - State:WA
Mailing Address - Zip Code:99033-0597
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:S 226 RAMSEY STR.
Practice Address - Street 2:
Practice Address - City:TEKOA
Practice Address - State:WA
Practice Address - Zip Code:99033-0597
Practice Address - Country:US
Practice Address - Phone:509-284-2423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9257601Medicaid