Provider Demographics
NPI:1255456968
Name:SOUTH FORK AMBULANCE ASSOCIATION
Entity type:Organization
Organization Name:SOUTH FORK AMBULANCE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-852-2362
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18105-0207
Mailing Address - Country:US
Mailing Address - Phone:484-664-2007
Mailing Address - Fax:
Practice Address - Street 1:28 MALL STREET
Practice Address - Street 2:
Practice Address - City:SOUTH FORK
Practice Address - State:CO
Practice Address - Zip Code:81154
Practice Address - Country:US
Practice Address - Phone:800-473-2278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO826590682OtherRR MEDICARE
CO06000749Medicaid
CO840765177OtherTRICARE
COS063893OtherBS
COS063893OtherBS