Healthcare Provider Details

I. General information

NPI: 1710956248
Provider Name (Legal Business Name): CITY OF BROKEN BOW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1848 S G ST
BROKEN BOW NE
68822-1825
US

IV. Provider business mailing address

1848 S G ST
BROKEN BOW NE
68822-1825
US

V. Phone/Fax

Practice location:
  • Phone: 308-872-1253
  • Fax: 308-872-2173
Mailing address:
  • Phone: 308-872-1253
  • Fax: 308-767-2651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number1065
License Number StateNE

VIII. Authorized Official

Name: ANDY CALVIN HOLLAND
Title or Position: EMERGENCY SERVICE DIRECTOR
Credential:
Phone: 308-872-1253