Provider Demographics
NPI:1770704587
Name:RED LAKE FALLS VOLUNTEER AMBULANCE ASSOCIATION
Entity type:Organization
Organization Name:RED LAKE FALLS VOLUNTEER AMBULANCE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLAIMS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-653-2201
Mailing Address - Street 1:PO BOX 194
Mailing Address - Street 2:
Mailing Address - City:RED LAKE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56750-0194
Mailing Address - Country:US
Mailing Address - Phone:651-653-2201
Mailing Address - Fax:
Practice Address - Street 1:201 CHAMPAGNE AVE SW
Practice Address - Street 2:
Practice Address - City:RED LAKE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56750-4003
Practice Address - Country:US
Practice Address - Phone:651-653-2201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN63663REOtherBCBS
MN491567400Medicaid
MN491567400Medicaid