Provider Demographics
NPI:1457438251
Name:NORTH BENTON AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:NORTH BENTON AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-887-3553
Mailing Address - Street 1:704 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52349-1174
Mailing Address - Country:US
Mailing Address - Phone:319-472-2091
Mailing Address - Fax:319-472-5629
Practice Address - Street 1:704 W 4TH ST
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349-1174
Practice Address - Country:US
Practice Address - Phone:319-472-2091
Practice Address - Fax:319-472-5629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2060500341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0063396Medicaid
IA0063396Medicaid