Healthcare Provider Details

I. General information

NPI: 1114926151
Provider Name (Legal Business Name): CANYON COUNTY AMBULANCE DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6116 GRAYE LANE
CALDWELL ID
83607-8072
US

IV. Provider business mailing address

6116 GRAYE LANE
CALDWELL ID
83607-8072
US

V. Phone/Fax

Practice location:
  • Phone: 208-795-6920
  • Fax: 208-795-6921
Mailing address:
  • Phone: 208-795-6920
  • Fax: 208-795-6921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number7479
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number8301
License Number StateID

VIII. Authorized Official

Name: MR. GREG D OWEN
Title or Position: DIRECTOR
Credential:
Phone: 208-795-6920