Provider Demographics
NPI:1679791412
Name:COUNTY OF CLARK
Entity Type:Organization
Organization Name:COUNTY OF CLARK
Other - Org Name:CLARK COUNTY AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COUNTY CLERK
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-374-5304
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:ID
Mailing Address - Zip Code:83423-0205
Mailing Address - Country:US
Mailing Address - Phone:208-374-5304
Mailing Address - Fax:208-374-5609
Practice Address - Street 1:332 W MAIN
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:ID
Practice Address - Zip Code:83423-0205
Practice Address - Country:US
Practice Address - Phone:208-374-5304
Practice Address - Fax:208-374-5609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0028083Medicaid
ID7702OtherSTATE LICENSE
ID1508044Medicare PIN