=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164484242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALLACE RURAL FIRE PROTECTION DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2006
-----------------------------------------------------
Last Update Date | 02/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 S COMMERCIAL AVE
-----------------------------------------------------
City | WALLACE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69169-8047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-218-4392
-----------------------------------------------------
Fax | 877-343-0131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10802 FARNAM DR
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68154-3237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-218-4392
-----------------------------------------------------
Fax | 877-343-0131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SEC. / TREAS.
-----------------------------------------------------
Name | MR. LYNN SWANSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 308-387-4307
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 1314
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------