Provider Demographics
NPI:1407969330
Name:CITY OF HORN LAKE
Entity Type:Organization
Organization Name:CITY OF HORN LAKE
Other - Org Name:CITY OF HORN LAKE AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MAYOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LATIMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-781-1157
Mailing Address - Street 1:3101 GOODMAN RD W
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1173
Mailing Address - Country:US
Mailing Address - Phone:662-342-0839
Mailing Address - Fax:662-280-1736
Practice Address - Street 1:6363 HIGHWAY 301
Practice Address - Street 2:
Practice Address - City:WALLS
Practice Address - State:MS
Practice Address - Zip Code:38680
Practice Address - Country:US
Practice Address - Phone:662-781-1157
Practice Address - Fax:662-781-7895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17703416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08657221Medicaid
MS=========OtherBLUE CROSS BLUE SHIELD
MS590920579Medicare ID - Type UnspecifiedPROVIDER NUMBER