Healthcare Provider Details

I. General information

NPI: 1174892210
Provider Name (Legal Business Name): CENTRAL CASCADES FIRE & EMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20400 CRESCENT LAKE HWY
CRESCENT LAKE OR
97733-7044
US

IV. Provider business mailing address

PO BOX 1065
CRESCENT LAKE OR
97733-1065
US

V. Phone/Fax

Practice location:
  • Phone: 541-433-2800
  • Fax:
Mailing address:
  • Phone: 541-433-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number133419
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number134610
License Number StateOR

VIII. Authorized Official

Name: SALLY R CARLSON
Title or Position: EMS DIRECTOR
Credential: EMT- BASIC
Phone: 541-433-2800