Provider Demographics
NPI:1376610576
Name:CITY OF EVANSDALE
Entity Type:Organization
Organization Name:CITY OF EVANSDALE
Other - Org Name:EVANSDALE FIRE AND RESCUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AMBULANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:SMOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-233-6930
Mailing Address - Street 1:123 N EVANS RD
Mailing Address - Street 2:
Mailing Address - City:EVANSDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50707-1115
Mailing Address - Country:US
Mailing Address - Phone:319-232-6683
Mailing Address - Fax:319-232-1586
Practice Address - Street 1:911 S EVANS RD
Practice Address - Street 2:
Practice Address - City:EVANSDALE
Practice Address - State:IA
Practice Address - Zip Code:50707-1647
Practice Address - Country:US
Practice Address - Phone:319-233-6930
Practice Address - Fax:319-274-8966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20704003416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0093773Medicaid
IA09377OtherBCBS
IA09377OtherBCBS