Healthcare Provider Details

I. General information

NPI: 1215934849
Provider Name (Legal Business Name): MEDIVAC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 CYCLONE AVE
HARLAN IA
51537-1300
US

IV. Provider business mailing address

812 CYCLONE AVE P.O. BOX 348
HARLAN IA
51537-1300
US

V. Phone/Fax

Practice location:
  • Phone: 712-755-3800
  • Fax: 712-755-7151
Mailing address:
  • Phone: 712-755-3800
  • Fax: 712-755-7151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number5105
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number2830700
License Number StateIA

VIII. Authorized Official

Name: MR. DAVID MILLER
Title or Position: GENERAL MANAGER
Credential:
Phone: 712-755-3800