Provider Demographics
NPI:1932278967
Name:PRIMGHAR
Entity Type:Organization
Organization Name:PRIMGHAR
Other - Org Name:PRIMGHAR AMBULANCE TEAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY CITY CLERK
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:EWOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-957-2435
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:PRIMGHAR
Mailing Address - State:IA
Mailing Address - Zip Code:51245-0039
Mailing Address - Country:US
Mailing Address - Phone:712-957-2435
Mailing Address - Fax:712-957-5300
Practice Address - Street 1:360 3RD ST. SE
Practice Address - Street 2:
Practice Address - City:PRIMGHAR
Practice Address - State:IA
Practice Address - Zip Code:51245-0039
Practice Address - Country:US
Practice Address - Phone:712-957-2435
Practice Address - Fax:712-957-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27104003416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0128280Medicaid
IA0128280Medicaid