Healthcare Provider Details

I. General information

NPI: 1669688735
Provider Name (Legal Business Name): VILLAGE OF MELROSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 5TH ST
MELROSE NM
88124-0398
US

IV. Provider business mailing address

PO BOX 641880
OMAHA NE
68164-7880
US

V. Phone/Fax

Practice location:
  • Phone: 575-253-4424
  • Fax:
Mailing address:
  • Phone: 402-572-4019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number53396
License Number StateNM

VIII. Authorized Official

Name: MR. KENNY L JACOBS
Title or Position: CHIEF
Credential:
Phone: 575-253-4424