Provider Demographics
NPI:1275687386
Name:SELBY VOLUNTEER AMBULANCE
Entity Type:Organization
Organization Name:SELBY VOLUNTEER AMBULANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-649-7362
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:SELBY
Mailing Address - State:SD
Mailing Address - Zip Code:57472-0192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2511 3RD AVE
Practice Address - Street 2:
Practice Address - City:SELBY
Practice Address - State:SD
Practice Address - Zip Code:57472-0192
Practice Address - Country:US
Practice Address - Phone:605-649-7362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6323416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0099140OtherBLUE CROSS BLUE SHIELD
SD9001230Medicaid
SDP00133441OtherRAILROAD MEDICARE
SDS99140Medicare ID - Type Unspecified
SD9001230Medicaid