MEDICARE: RED LAKE FALLS VOLUNTEER AMBULANCE ASSOCIATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance		MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	63663RE	OTHER	MN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770704587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RED LAKE FALLS VOLUNTEER AMBULANCE ASSOCIATION

Provider Business Mailing Address
First Line	:	PO BOX 194
Second Line	:
City	:	RED LAKE FALLS
State	:	MN
Zip	:	56750-0194
Country	:	US
Telephone Number	:	651-653-2201
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 CHAMPAGNE AVE SW
Second Line	:
City	:	RED LAKE FALLS
State	:	MN
Zip	:	56750-4003
Country	:	US
Telephone Number	:	651-653-2201
Fax Number	:

Authorized Official
Title or Position	:	CLAIMS MANAGER
Name	:	DIANE TALLACKSON
Credential	:
Telephone Number	:	651-653-2201

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	12/04/2013

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