Provider Demographics
NPI:1700883113
Name:BEAVER DAM LITTLEFIELD FIRE DISTRICT
Entity Type:Organization
Organization Name:BEAVER DAM LITTLEFIELD FIRE DISTRICT
Other - Org Name:BEAVER DAM AMBULANCE
Other - Org Type:Other Name
Authorized Official - Title/Position:CAPTAIN
Authorized Official - Prefix:
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-347-5114
Mailing Address - Street 1:PO BOX 4451
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-4451
Mailing Address - Country:US
Mailing Address - Phone:928-567-0403
Mailing Address - Fax:928-567-6403
Practice Address - Street 1:630 N HWY 91
Practice Address - Street 2:
Practice Address - City:LITTLEFIELD
Practice Address - State:AZ
Practice Address - Zip Code:86432-0579
Practice Address - Country:US
Practice Address - Phone:928-347-5114
Practice Address - Fax:928-347-5273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1243416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00371415OtherRAILROAD MEDICARE
UT(EIN)-001Medicaid
AZ747173Medicaid
AZZ75652Medicare PIN