Healthcare Provider Details

I. General information

NPI: 1689787715
Provider Name (Legal Business Name): GREAT DIVIDE AMBULANCE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43555 US HIGHWAY 63
CABLE WI
54821-2000
US

IV. Provider business mailing address

43555 US HIGHWAY 63
CABLE WI
54821-2000
US

V. Phone/Fax

Practice location:
  • Phone: 715-798-3094
  • Fax: 715-798-4442
Mailing address:
  • Phone: 715-798-3094
  • Fax: 336-510-5894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: ROY BLOOM
Title or Position: SERVICE DIRECTOR
Credential:
Phone: 715-798-3094