Provider Demographics
NPI:1053504829
Name:POTLATCH RURAL FIRE DIST
Entity Type:Organization
Organization Name:POTLATCH RURAL FIRE DIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBULANCE COMMISSIONER
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:COY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-875-0139
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:POTLATCH
Mailing Address - State:ID
Mailing Address - Zip Code:83855-0063
Mailing Address - Country:US
Mailing Address - Phone:208-875-0139
Mailing Address - Fax:
Practice Address - Street 1:512 PINE STREET
Practice Address - Street 2:
Practice Address - City:POTLATCH
Practice Address - State:ID
Practice Address - Zip Code:83855
Practice Address - Country:US
Practice Address - Phone:208-875-0139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID72063416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID15003721OtherMEDICARE PTAN
ID15003721OtherMEDICARE PTAN