Healthcare Provider Details

I. General information

NPI: 1174130074
Provider Name (Legal Business Name): SHOSHONE COUNTY AMBULANCE SERVICE DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58738 SILVER VALLEY ROAD
OSBURN ID
83849
US

IV. Provider business mailing address

PO BOX 488
OSBURN ID
83849-0488
US

V. Phone/Fax

Practice location:
  • Phone: 208-512-2660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State

VIII. Authorized Official

Name: MR. JERRY JOHN BRANTZ
Title or Position: SECRETARY/TREASURER - BOARD MEMBER
Credential:
Phone: 208-752-1101