Provider Demographics
NPI:1265514756
Name:SARGENT COUNTY AMBULANCE FORMAN SQUAD
Entity type:Organization
Organization Name:SARGENT COUNTY AMBULANCE FORMAN SQUAD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-724-6241
Mailing Address - Street 1:PO BOX 316
Mailing Address - Street 2:
Mailing Address - City:FORMAN
Mailing Address - State:ND
Mailing Address - Zip Code:58032-0316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 MAIN ST S
Practice Address - Street 2:
Practice Address - City:FORMAN
Practice Address - State:ND
Practice Address - Zip Code:58032
Practice Address - Country:US
Practice Address - Phone:701-724-6241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND040341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND7298OtherBLUE CROSS BLUE SHIELD
ND50033Medicaid
NDN7298Medicare ID - Type Unspecified
ND7298OtherBLUE CROSS BLUE SHIELD
NDN7298Medicare PIN