Provider Demographics
NPI:1376625319
Name:SOUTHERN WASCO COUNTY AMBULANCE SERVICE INC
Entity Type:Organization
Organization Name:SOUTHERN WASCO COUNTY AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-395-2598
Mailing Address - Street 1:PO BOX 3510
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-3510
Mailing Address - Country:US
Mailing Address - Phone:360-394-7030
Mailing Address - Fax:360-394-7094
Practice Address - Street 1:390 3RD ST
Practice Address - Street 2:
Practice Address - City:MAUPIN
Practice Address - State:OR
Practice Address - Zip Code:97037-9246
Practice Address - Country:US
Practice Address - Phone:541-395-2598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3303-043416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9032186Medicaid
OR179119Medicaid
OR590007776Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WA9032186Medicaid