Healthcare Provider Details

I. General information

NPI: 1285693861
Provider Name (Legal Business Name): NORTHEAST IOWA MEDICAL TRANSPORT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 N VINE ST
WEST UNION IA
52175-1018
US

IV. Provider business mailing address

704 N VINE ST
WEST UNION IA
52175-1018
US

V. Phone/Fax

Practice location:
  • Phone: 563-422-3723
  • Fax: 563-422-3723
Mailing address:
  • Phone: 563-422-3723
  • Fax: 563-422-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number2330400
License Number StateIA

VIII. Authorized Official

Name: MR. REGINALD HENRY GROSS
Title or Position: CEO
Credential: PARAMEDIC, CRITICAL
Phone: 563-422-9459