Provider Demographics
NPI:1659376176
Name:GRAND RIVER REGIONAL AMBULANCE DISTRICT
Entity Type:Organization
Organization Name:GRAND RIVER REGIONAL AMBULANCE DISTRICT
Other - Org Name:GRAND RIVER AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:STEGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-783-2430
Mailing Address - Street 1:PO BOX 105
Mailing Address - Street 2:
Mailing Address - City:STANBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:64489
Mailing Address - Country:US
Mailing Address - Phone:660-783-2430
Mailing Address - Fax:660-783-2804
Practice Address - Street 1:GRAND RIVER REGIONAL AMBULANCE DISTRICT
Practice Address - Street 2:810 N ALANTHUS AVE.
Practice Address - City:STANBERRY
Practice Address - State:MO
Practice Address - Zip Code:64489
Practice Address - Country:US
Practice Address - Phone:660-783-2430
Practice Address - Fax:660-783-2804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0750353416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO16949018OtherBC/BS PROVIDER NUMBER
MO802478701Medicaid