Provider Demographics
NPI:1134122591
Name:VICI - CAMARGO EMS
Entity Type:Organization
Organization Name:VICI - CAMARGO EMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COLETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-995-3350
Mailing Address - Street 1:PO BOX 239
Mailing Address - Street 2:
Mailing Address - City:VICI
Mailing Address - State:OK
Mailing Address - Zip Code:73859-0239
Mailing Address - Country:US
Mailing Address - Phone:580-995-3350
Mailing Address - Fax:
Practice Address - Street 1:619 MAIN ST
Practice Address - Street 2:
Practice Address - City:VICI
Practice Address - State:OK
Practice Address - Zip Code:73859
Practice Address - Country:US
Practice Address - Phone:580-995-3350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS0173416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========Medicare ID - Type Unspecified