Provider Demographics
NPI:1265682694
Name:IDAHO MEDICAL TRANSPORT
Entity Type:Organization
Organization Name:IDAHO MEDICAL TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHEL
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:PRUIETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-777-7719
Mailing Address - Street 1:1924 E PREAKNESS AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9428
Mailing Address - Country:US
Mailing Address - Phone:208-777-7719
Mailing Address - Fax:
Practice Address - Street 1:1924 E PREAKNESS AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9428
Practice Address - Country:US
Practice Address - Phone:208-777-7719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance