Provider Demographics
NPI:1083758668
Name:TOWN OF VIDALIA
Entity Type:Organization
Organization Name:TOWN OF VIDALIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:TAUNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-336-6262
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-2010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 VERNON STEVENS BLVD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-5001
Practice Address - Country:US
Practice Address - Phone:318-336-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9110062341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC8277OtherBCBS
LA590012309OtherRAILROAD MEDICARE
LA1697516Medicaid
LA1697516Medicaid