Provider Demographics
NPI:1033112776
Name:LEEDEY AMBULANCE SERVICE
Entity Type:Organization
Organization Name:LEEDEY AMBULANCE SERVICE
Other - Org Name:LEEDEY AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WOHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-488-2101
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:LEEDEY
Mailing Address - State:OK
Mailing Address - Zip Code:73654-0190
Mailing Address - Country:US
Mailing Address - Phone:580-488-3812
Mailing Address - Fax:580-488-2191
Practice Address - Street 1:401 S MAIN
Practice Address - Street 2:
Practice Address - City:LEEDEY
Practice Address - State:OK
Practice Address - Zip Code:73654
Practice Address - Country:US
Practice Address - Phone:580-488-3812
Practice Address - Fax:580-488-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-26
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS1133416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK590007407OtherRAILROAD MEDICARE
OK100818750AMedicaid
OK100818750AMedicaid