Provider Demographics
NPI:1265634323
Name:SAN JUAN COUNTY FIRE DISTRICT #4
Entity Type:Organization
Organization Name:SAN JUAN COUNTY FIRE DISTRICT #4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:UNGARETTI
Authorized Official - Suffix:
Authorized Official - Credentials:CCEMTP
Authorized Official - Phone:406-549-7104
Mailing Address - Street 1:1008 BURLINGTON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5681
Mailing Address - Country:US
Mailing Address - Phone:406-549-7104
Mailing Address - Fax:406-542-2785
Practice Address - Street 1:2228 FISHERMAN BAY RD
Practice Address - Street 2:
Practice Address - City:LOPEZ ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98261-8676
Practice Address - Country:US
Practice Address - Phone:360-468-2991
Practice Address - Fax:360-468-3716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA28D04341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9046061Medicaid