Provider Demographics
NPI:1821149535
Name:CITY OF PINE BLUFFS
Entity Type:Organization
Organization Name:CITY OF PINE BLUFFS
Other - Org Name:PINE BLUFFS-EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:R
Authorized Official - Last Name:WELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-245-3400
Mailing Address - Street 1:PO BOX 641880
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-7880
Mailing Address - Country:US
Mailing Address - Phone:402-572-4019
Mailing Address - Fax:402-965-8594
Practice Address - Street 1:220 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PINE BLUFFS
Practice Address - State:WY
Practice Address - Zip Code:82082-0429
Practice Address - Country:US
Practice Address - Phone:307-245-3746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY63341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY306502OtherBLUE CROSS BLUE SHIELD
WY114308500Medicaid
WYW306502Medicare ID - Type Unspecified