Provider Demographics
NPI:1932305349
Name:CITY OF GRAVETTE
Entity Type:Organization
Organization Name:CITY OF GRAVETTE
Other - Org Name:GRAVETTE FIRE AND AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MAYOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-787-7575
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-8642
Practice Address - Street 1:309 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:GRAVETTE
Practice Address - State:AR
Practice Address - Zip Code:72736
Practice Address - Country:US
Practice Address - Phone:479-787-6600
Practice Address - Fax:479-787-6162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X, 3416L0300X
AR175341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101128715Medicaid
47058OtherBLUE CROSS
AR47058Medicare ID - Type Unspecified