Provider Demographics
NPI:1659424042
Name:CITY OF BOKCHITO
Entity Type:Organization
Organization Name:CITY OF BOKCHITO
Other - Org Name:EASTERN BRYAN COUNTY AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNDRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-295-3775
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:117 EAST MAIN STREET
Mailing Address - City:BOKCHITO
Mailing Address - State:OK
Mailing Address - Zip Code:74726-0007
Mailing Address - Country:US
Mailing Address - Phone:580-295-3775
Mailing Address - Fax:580-295-3777
Practice Address - Street 1:117 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BOKCHITO
Practice Address - State:OK
Practice Address - Zip Code:74726-0007
Practice Address - Country:US
Practice Address - Phone:580-295-3775
Practice Address - Fax:580-295-3777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2373416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBCBS BILLING NUMBER
OK=========001OtherBCBS BILLING NUMBER