Healthcare Provider Details

I. General information

NPI: 1689778391
Provider Name (Legal Business Name): MEADOW VALLEY AMBULANCE SERVICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HWY 95
NEW MEADOWS ID
83654
US

IV. Provider business mailing address

PO BOX 532
NEW MEADOWS ID
83654-0532
US

V. Phone/Fax

Practice location:
  • Phone: 208-347-3190
  • Fax:
Mailing address:
  • Phone: 208-469-0005
  • Fax: 208-347-3190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number#5313
License Number StateID

VIII. Authorized Official

Name: JACOB MAC QUALLS
Title or Position: EMS CHIEF
Credential:
Phone: 208-469-0005