Healthcare Provider Details

I. General information

NPI: 1922079458
Provider Name (Legal Business Name): PUERCO VALLEY AMBULANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S HWY 191
SANDERS AZ
86512
US

IV. Provider business mailing address

PO BOX 39
SANDERS AZ
86512-0039
US

V. Phone/Fax

Practice location:
  • Phone: 928-688-3616
  • Fax: 928-688-2922
Mailing address:
  • Phone: 928-688-3616
  • Fax: 928-688-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number116
License Number StateAZ

VIII. Authorized Official

Name: TAMI WOOD
Title or Position: ASSISTANT ADMIN CHIEF
Credential:
Phone: 928-688-3616