Provider Demographics
NPI:1881766525
Name:GLEN ULLIN AMBULANCE SERVICE
Entity type:Organization
Organization Name:GLEN ULLIN AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SQUAD LEADER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUPPONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-348-3274
Mailing Address - Street 1:PO BOX 974
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-0974
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 2ND ST SOUTH
Practice Address - Street 2:
Practice Address - City:GLEN ULLIN
Practice Address - State:ND
Practice Address - Zip Code:58631
Practice Address - Country:US
Practice Address - Phone:701-348-3274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND44341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND052187Medicaid
NDGLE7178OtherBLUE CROSS ND
NDN7178Medicare PIN