Provider Demographics
NPI:1184785248
Name:CLEARWATER COUNTY DBA BACK COUNTRY MEDICS
Entity type:Organization
Organization Name:CLEARWATER COUNTY DBA BACK COUNTRY MEDICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:ALBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-476-3057
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:150 MICHIGAN AVE
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-0586
Mailing Address - Country:US
Mailing Address - Phone:208-476-5615
Mailing Address - Fax:208-476-9315
Practice Address - Street 1:1060 AIRPORT ROAD
Practice Address - Street 2:BOX 586
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-0586
Practice Address - Country:US
Practice Address - Phone:208-476-5615
Practice Address - Fax:208-476-9315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62283416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9062621Medicaid
ID808479400Medicaid
1514500Medicare Oscar/Certification
ID808479400Medicaid