Provider Demographics
NPI:1699853788
Name:BOYD EDSON DELMAR FD AMBULANCE
Entity Type:Organization
Organization Name:BOYD EDSON DELMAR FD AMBULANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBULANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:SUPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-667-3255
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:BOYD
Mailing Address - State:WI
Mailing Address - Zip Code:54726
Mailing Address - Country:US
Mailing Address - Phone:715-667-3255
Mailing Address - Fax:715-667-3031
Practice Address - Street 1:100 S OSHKOSH ST
Practice Address - Street 2:
Practice Address - City:BOYD
Practice Address - State:WI
Practice Address - Zip Code:54726
Practice Address - Country:US
Practice Address - Phone:715-667-3255
Practice Address - Fax:715-667-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6000352341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41336400Medicaid