Provider Demographics
NPI:1770512600
Name:COUNTY OF MOODY
Entity Type:Organization
Organization Name:COUNTY OF MOODY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUT REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-882-9911
Mailing Address - Street 1:108 E PIPESTONE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-1759
Mailing Address - Country:US
Mailing Address - Phone:877-882-9911
Mailing Address - Fax:877-882-9922
Practice Address - Street 1:108 E PIPESTONE AVE STE B
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1759
Practice Address - Country:US
Practice Address - Phone:877-882-9911
Practice Address - Fax:877-882-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5213416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9010260Medicaid
SDD25374Medicare UPIN
SD9010260Medicaid