Provider Demographics
NPI:1467649806
Name:VILLAGE OF ANGEL FIRE
Entity Type:Organization
Organization Name:VILLAGE OF ANGEL FIRE
Other - Org Name:ANGEL FIRE EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIRE DEPARTMENT CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-377-3347
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:ANGEL FIRE
Mailing Address - State:NM
Mailing Address - Zip Code:87710-0610
Mailing Address - Country:US
Mailing Address - Phone:505-377-3347
Mailing Address - Fax:505-377-6098
Practice Address - Street 1:11 N ANGEL FIRE ROAD
Practice Address - Street 2:
Practice Address - City:ANGEL FIRE
Practice Address - State:NM
Practice Address - Zip Code:87710
Practice Address - Country:US
Practice Address - Phone:505-377-3347
Practice Address - Fax:505-377-6098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMG53792343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN0175Medicaid