Provider Demographics
NPI:1710946348
Name:LOWER BRULE AMBULANCE
Entity Type:Organization
Organization Name:LOWER BRULE AMBULANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:DOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-473-5293
Mailing Address - Street 1:187 OYATE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LOWER BRULE
Mailing Address - State:SD
Mailing Address - Zip Code:57548-0187
Mailing Address - Country:US
Mailing Address - Phone:605-473-5293
Mailing Address - Fax:605-473-1058
Practice Address - Street 1:BIA ROUTE 3
Practice Address - Street 2:
Practice Address - City:LOWER BRULE
Practice Address - State:SD
Practice Address - Zip Code:57548-0817
Practice Address - Country:US
Practice Address - Phone:605-473-5293
Practice Address - Fax:605-473-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD451341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9002150Medicaid
SD9002150Medicaid