Provider Demographics
NPI:1700051471
Name:MIDVALE FIRE PROTECTION DISTRICT
Entity Type:Organization
Organization Name:MIDVALE FIRE PROTECTION DISTRICT
Other - Org Name:MIDVALE AMBULANCE
Other - Org Type:Other Name
Authorized Official - Title/Position:EMS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-550-1605
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:ID
Mailing Address - Zip Code:83645-0131
Mailing Address - Country:US
Mailing Address - Phone:208-550-1605
Mailing Address - Fax:
Practice Address - Street 1:10 S RIVER STREET
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:ID
Practice Address - Zip Code:83645
Practice Address - Country:US
Practice Address - Phone:208-550-1605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53173416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0024624Medicaid
ID000010014799OtherBLUE SHIELD