Provider Demographics
NPI:1780630616
Name:MISSION VALLEY AMBULANCE
Entity Type:Organization
Organization Name:MISSION VALLEY AMBULANCE
Other - Org Name:MISSION VALLEY AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:UMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:EMT
Authorized Official - Phone:406-745-4190
Mailing Address - Street 1:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-1359
Mailing Address - Country:US
Mailing Address - Phone:406-549-7104
Mailing Address - Fax:406-542-2785
Practice Address - Street 1:32 FIRST AVE
Practice Address - Street 2:
Practice Address - City:ST IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865
Practice Address - Country:US
Practice Address - Phone:406-745-4190
Practice Address - Fax:406-745-2757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT883416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT329880700OtherOWCP WORKERS COMP
MT0442013Medicaid
MT65012OtherBCBS
MT590005766Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MT65012OtherBCBS