Provider Demographics
NPI:1912084716
Name:SHENANDOAH AMBULANCE SERVICE
Entity Type:Organization
Organization Name:SHENANDOAH AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-246-7100
Mailing Address - Street 1:300 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-2355
Mailing Address - Country:US
Mailing Address - Phone:712-246-1230
Mailing Address - Fax:712-246-7357
Practice Address - Street 1:300 PERSHING AVE
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-2355
Practice Address - Country:US
Practice Address - Phone:712-246-1230
Practice Address - Fax:712-246-7357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27308003416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0228569Medicaid
IA0228569Medicaid