Provider Demographics
NPI:1477569267
Name:CITY OF LAKE PRESTON
Entity Type:Organization
Organization Name:CITY OF LAKE PRESTON
Other - Org Name:LAKE PRESTON AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-847-4140
Mailing Address - Street 1:30177 422ND AVE
Mailing Address - Street 2:
Mailing Address - City:TYNDALL
Mailing Address - State:SD
Mailing Address - Zip Code:57066
Mailing Address - Country:US
Mailing Address - Phone:605-464-0382
Mailing Address - Fax:605-589-3672
Practice Address - Street 1:111 3RD ST NE
Practice Address - Street 2:
Practice Address - City:LAKE PRESTON
Practice Address - State:SD
Practice Address - Zip Code:57249-0397
Practice Address - Country:US
Practice Address - Phone:605-847-4140
Practice Address - Fax:605-847-4140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD04243416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9000340Medicaid
SD9000340Medicaid