Provider Demographics
NPI:1346386117
Name:COUNTY OF MELLETTE
Entity Type:Organization
Organization Name:COUNTY OF MELLETTE
Other - Org Name:MELLETTE COUNTY AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-259-3371
Mailing Address - Street 1:PO BOX C
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER
Mailing Address - State:SD
Mailing Address - Zip Code:57579
Mailing Address - Country:US
Mailing Address - Phone:605-259-3099
Mailing Address - Fax:605-259-3194
Practice Address - Street 1:415 NORTH ROOSEVELT STREET
Practice Address - Street 2:
Practice Address - City:WHITE RIVER
Practice Address - State:SD
Practice Address - Zip Code:57579
Practice Address - Country:US
Practice Address - Phone:605-259-3099
Practice Address - Fax:605-259-3194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2018-09-26
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-09-11
Provider Licenses
StateLicense IDTaxonomies
SD502341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
S99089Medicare PIN