Provider Demographics
NPI: | 1891828554 |
---|---|
Name: | VILLAGE OF CLOUDCROFT |
Entity Type: | Organization |
Organization Name: | VILLAGE OF CLOUDCROFT |
Other - Org Name: | CLOUDCROFT AMBULANCE SERVICE |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | EMS DIRECTOR |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | STEVE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GRULKE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 505-682-2411 |
Mailing Address - Street 1: | PO BOX 317 |
Mailing Address - Street 2: | |
Mailing Address - City: | CLOUDCROFT |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 88317-0317 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 505-682-2411 |
Mailing Address - Fax: | 505-682-2042 |
Practice Address - Street 1: | 1100 JAMES CANYON HWY |
Practice Address - Street 2: | |
Practice Address - City: | CLOUDCROFT |
Practice Address - State: | NM |
Practice Address - Zip Code: | 88317-0317 |
Practice Address - Country: | US |
Practice Address - Phone: | 505-682-3409 |
Practice Address - Fax: | 505-682-1102 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-03-13 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 341600000X | Transportation Services | Ambulance |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NM | A2667 | Medicaid |