Provider Demographics
NPI:1932167640
Name:MEMORIAL AMBULANCE OF FORT BENTON MONTANA
Entity Type:Organization
Organization Name:MEMORIAL AMBULANCE OF FORT BENTON MONTANA
Other - Org Name:MEMORIAL AMBULANCE SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:SERVICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:L
Authorized Official - Last Name:HURT
Authorized Official - Suffix:
Authorized Official - Credentials:NREMTP
Authorized Official - Phone:406-301-4288
Mailing Address - Street 1:PO BOX 2458
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MT
Mailing Address - Zip Code:59917-2458
Mailing Address - Country:US
Mailing Address - Phone:406-297-1627
Mailing Address - Fax:855-574-5392
Practice Address - Street 1:810 15TH ST
Practice Address - Street 2:
Practice Address - City:FORT BENTON
Practice Address - State:MT
Practice Address - Zip Code:59442-8993
Practice Address - Country:US
Practice Address - Phone:406-622-3400
Practice Address - Fax:406-622-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT143416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0445068Medicaid
MT1352OtherBC/BS
MT1352OtherBC/BS
MT0445068Medicaid