Provider Demographics
NPI:1467476119
Name:CITY OF COLLEYVILLE
Entity Type:Organization
Organization Name:CITY OF COLLEYVILLE
Other - Org Name:COLLEYVILLE FIRE DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EMS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-581-4591
Mailing Address - Street 1:5209 COLLEYVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5830
Mailing Address - Country:US
Mailing Address - Phone:817-581-4591
Mailing Address - Fax:817-581-4538
Practice Address - Street 1:5209 COLLEYVILLE BLVD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5830
Practice Address - Country:US
Practice Address - Phone:817-581-4591
Practice Address - Fax:817-581-4538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2200063416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX514291OtherBC/BS OF TEXAS
TX000375801Medicaid
TX514291Medicare PIN
TX514291OtherBC/BS OF TEXAS