Provider Demographics
NPI:1982794939
Name:CITY OF PLAZA
Entity Type:Organization
Organization Name:CITY OF PLAZA
Other - Org Name:PLAZA AMBULANCE
Other - Org Type:Other Name
Authorized Official - Title/Position:SERVICE LEADER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:EMT B
Authorized Official - Phone:701-497-3766
Mailing Address - Street 1:409 4TH AVE COVELL ST
Mailing Address - Street 2:BOX 57
Mailing Address - City:PLAZA
Mailing Address - State:ND
Mailing Address - Zip Code:58771-0057
Mailing Address - Country:US
Mailing Address - Phone:701-720-3311
Mailing Address - Fax:
Practice Address - Street 1:409 4TH AVE COVELL ST
Practice Address - Street 2:
Practice Address - City:PLAZA
Practice Address - State:ND
Practice Address - Zip Code:58771-0057
Practice Address - Country:US
Practice Address - Phone:701-497-3368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1043416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN7345Medicare PIN