Provider Demographics
NPI:1659301588
Name:ROCKY MOUNTAIN AMBULANCE SERVICE LLC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN AMBULANCE SERVICE LLC
Other - Org Name:ROCKY MOUNTAIN AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-673-8303
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-5011
Mailing Address - Country:US
Mailing Address - Phone:270-824-8123
Mailing Address - Fax:270-824-8140
Practice Address - Street 1:731 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3600
Practice Address - Country:US
Practice Address - Phone:307-673-8303
Practice Address - Fax:307-673-7178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1043416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115242400Medicaid