Provider Demographics
NPI:1851451207
Name:GRANT-ROBERTS AMBULANCE, INC.
Entity Type:Organization
Organization Name:GRANT-ROBERTS AMBULANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARRET
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-432-6783
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:MILBANK
Mailing Address - State:SD
Mailing Address - Zip Code:57252-0623
Mailing Address - Country:US
Mailing Address - Phone:605-432-6783
Mailing Address - Fax:
Practice Address - Street 1:306 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MILBANK
Practice Address - State:SD
Practice Address - Zip Code:57252-1818
Practice Address - Country:US
Practice Address - Phone:605-432-6783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD02913416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9017010Medicaid
SD0005222OtherBLUE CROSS BLUE SHIELD
SDS5222Medicare PIN