Provider Demographics
NPI:1457631632
Name:PONDEROSA FIRE DISTRICT
Entity Type:Organization
Organization Name:PONDEROSA FIRE DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-773-8933
Mailing Address - Street 1:PO BOX 16359
Mailing Address - Street 2:
Mailing Address - City:BELLEMONT
Mailing Address - State:AZ
Mailing Address - Zip Code:86015-6359
Mailing Address - Country:US
Mailing Address - Phone:928-773-8933
Mailing Address - Fax:
Practice Address - Street 1:11951 W. SHADOW MOUNTAIN DRIVE
Practice Address - Street 2:
Practice Address - City:BELLEMONT
Practice Address - State:AZ
Practice Address - Zip Code:86015
Practice Address - Country:US
Practice Address - Phone:928-773-8933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty