Provider Demographics
NPI:1225031891
Name:MTN. VIEW-GOTEBO AMBULANCE SERVICE
Entity Type:Organization
Organization Name:MTN. VIEW-GOTEBO AMBULANCE SERVICE
Other - Org Name:MOUNTAIN VIEW - GOTEBO AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DEMARCUS
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:580-347-2268
Mailing Address - Street 1:BOX 294
Mailing Address - Street 2:
Mailing Address - City:MT. VIEW
Mailing Address - State:OK
Mailing Address - Zip Code:73062-0294
Mailing Address - Country:US
Mailing Address - Phone:580-347-2268
Mailing Address - Fax:580-347-2268
Practice Address - Street 1:319 NORTH THIRD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:OK
Practice Address - Zip Code:73062-0294
Practice Address - Country:US
Practice Address - Phone:580-347-2268
Practice Address - Fax:580-347-2268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS1043416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100818850AMedicaid
OK=========-001OtherBCBS PROVIDER #
OK=========-001OtherBCBS PROVIDER #
OK731056989Medicare ID - Type Unspecified