Provider Demographics
NPI:1639230790
Name:KIOWA COUNTY DISTRICT THREE EMERGENCY AMBULANCE ASSOCIATION
Entity Type:Organization
Organization Name:KIOWA COUNTY DISTRICT THREE EMERGENCY AMBULANCE ASSOCIATION
Other - Org Name:KIOWA COUNTY DISTRICT THREE EMERGENCY AMBULANCE ASSOCIATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MCPHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-569-2778
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:206 SPRUCE STREET
Mailing Address - City:MOUNTAIN PARK
Mailing Address - State:OK
Mailing Address - Zip Code:73559-0220
Mailing Address - Country:US
Mailing Address - Phone:580-569-2908
Mailing Address - Fax:580-569-2908
Practice Address - Street 1:206 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:MOUNTAIN PARK
Practice Address - State:OK
Practice Address - Zip Code:73559-0220
Practice Address - Country:US
Practice Address - Phone:580-569-2908
Practice Address - Fax:580-569-2908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK052341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK590002665OtherRAILROAD MEDICARE
OK892540001-001OtherBC/BS
OK100818890AMedicaid
OK892540001-001OtherBLUE CROSS BLUE SHIELD
OK731068986Medicare ID - Type Unspecified
OK892540001-001OtherBC/BS