Provider Demographics
NPI:1336367861
Name:GREAT WEST AMBULANCE SERVICE
Entity Type:Organization
Organization Name:GREAT WEST AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:NAVARRE
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-A
Authorized Official - Phone:307-333-1219
Mailing Address - Street 1:2036 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3518
Mailing Address - Country:US
Mailing Address - Phone:307-333-1219
Mailing Address - Fax:307-333-1219
Practice Address - Street 1:2036 NOTTINGHAM DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3518
Practice Address - Country:US
Practice Address - Phone:307-333-1219
Practice Address - Fax:307-333-1219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW21341Medicare PIN