Provider Demographics
NPI:1790810661
Name:SHOSHONE BANNOCK TRIBES, INC.
Entity Type:Organization
Organization Name:SHOSHONE BANNOCK TRIBES, INC.
Other - Org Name:FORT HALL FIRE & EMS DISTRICT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:VAL
Authorized Official - Middle Name:
Authorized Official - Last Name:NAVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-478-3784
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:FORT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203-0306
Mailing Address - Country:US
Mailing Address - Phone:208-478-3786
Mailing Address - Fax:208-478-3788
Practice Address - Street 1:700 WIDOWVILLE ROAD
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203-0306
Practice Address - Country:US
Practice Address - Phone:208-478-3786
Practice Address - Fax:208-478-3788
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHOSHONE BANNOCK TRIBES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-22
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2626341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806350000Medicaid
IDID806350000Medicaid
ID1514028Medicare ID - Type Unspecified
IDID806350000Medicaid
ID806350000Medicaid