Provider Demographics
NPI:1396842332
Name:CITY OF WILLISTON
Entity Type:Organization
Organization Name:CITY OF WILLISTON
Other - Org Name:WILLISTON COMMUNITY AMBULANCE SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:CITY AUDITOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUTZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-577-8100
Mailing Address - Street 1:PO BOX 1306
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-1306
Mailing Address - Country:US
Mailing Address - Phone:701-577-8100
Mailing Address - Fax:701-577-8880
Practice Address - Street 1:22 E BROADWAY
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-6011
Practice Address - Country:US
Practice Address - Phone:701-577-8100
Practice Address - Fax:701-577-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND131341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT440700Medicaid
ND50101Medicaid
ND7008OtherBLUE CROSS BLUE SHIELD
ND7008OtherBLUE CROSS BLUE SHIELD
ND791590193Medicare ID - Type UnspecifiedPALMETTO GBA