Provider Demographics
NPI:1710912381
Name:PULASKI COUNTY AMBULANCE DISTRICT
Entity Type:Organization
Organization Name:PULASKI COUNTY AMBULANCE DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CARMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MA, EMT-P
Authorized Official - Phone:573-774-2807
Mailing Address - Street 1:PO BOX 466
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-0466
Mailing Address - Country:US
Mailing Address - Phone:573-774-2807
Mailing Address - Fax:573-774-2748
Practice Address - Street 1:1601 OUSLEY RD
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-3532
Practice Address - Country:US
Practice Address - Phone:573-774-2807
Practice Address - Fax:573-774-2748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1690303416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000007326OtherMEDICARE PTAN
MO802454108Medicaid