Provider Demographics
NPI:1679617781
Name:IDALIA AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:IDALIA AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOELLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-I
Authorized Official - Phone:970-354-7285
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:IDALIA
Mailing Address - State:CO
Mailing Address - Zip Code:80735-0055
Mailing Address - Country:US
Mailing Address - Phone:970-354-7285
Mailing Address - Fax:
Practice Address - Street 1:9141 RD CC.8
Practice Address - Street 2:
Practice Address - City:IDALIA
Practice Address - State:CO
Practice Address - Zip Code:80735
Practice Address - Country:US
Practice Address - Phone:970-354-7285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Single Specialty
Not Answered146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC62343Medicare ID - Type Unspecified