Provider Demographics
NPI:1578654778
Name:BACK MOUNTAIN REGIONAL FIRE AND EMS INC
Entity Type:Organization
Organization Name:BACK MOUNTAIN REGIONAL FIRE AND EMS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:VANETTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-675-0636
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-0176
Mailing Address - Country:US
Mailing Address - Phone:570-675-0636
Mailing Address - Fax:570-675-3883
Practice Address - Street 1:184 E CENTER HILL RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-1154
Practice Address - Country:US
Practice Address - Phone:570-675-0636
Practice Address - Fax:570-675-3883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA080036800OtherFEDERAL BLACK LUNG
PA0016641770001Medicaid
PA338170OtherHEALTH AMERICA
PA0016641770001Medicaid
590012298Medicare PIN