Provider Demographics
NPI:1841291630
Name:CLARK FORK VALLEY AMBULANCE SERVICE, INC.
Entity type:Organization
Organization Name:CLARK FORK VALLEY AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR & ACCTS REC'BLE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-610-3164
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:CLARK FORK
Mailing Address - State:ID
Mailing Address - Zip Code:83811-0464
Mailing Address - Country:US
Mailing Address - Phone:208-266-1161
Mailing Address - Fax:208-266-0219
Practice Address - Street 1:111 EAST 2ND
Practice Address - Street 2:
Practice Address - City:CLARK FORK
Practice Address - State:ID
Practice Address - Zip Code:83811-0464
Practice Address - Country:US
Practice Address - Phone:208-266-1161
Practice Address - Fax:208-266-0219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID61033416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1504745OtherPTAN
ID002459300Medicaid