Provider Demographics
NPI:1437120359
Name:KEYSTONE AMBULANCE SERVICE INC.
Entity Type:Organization
Organization Name:KEYSTONE AMBULANCE SERVICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MULLOY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:605-666-5033
Mailing Address - Street 1:BOX 175
Mailing Address - Street 2:1005 HARNEY STREET
Mailing Address - City:KEYSTONE
Mailing Address - State:SD
Mailing Address - Zip Code:57751-0175
Mailing Address - Country:US
Mailing Address - Phone:605-666-5033
Mailing Address - Fax:605-666-5236
Practice Address - Street 1:1005 HARNEY STREET
Practice Address - Street 2:BOX 175
Practice Address - City:KEYSTONE
Practice Address - State:SD
Practice Address - Zip Code:57751-0175
Practice Address - Country:US
Practice Address - Phone:605-666-5033
Practice Address - Fax:605-666-5236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0253416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9002930Medicaid
SD9002930Medicaid