=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174261010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY EMS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2022
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 S MAIN STREET
-----------------------------------------------------
City | SAVANNA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74565-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-698-4845
-----------------------------------------------------
Fax | 580-628-2267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1548
-----------------------------------------------------
City | MCALESTER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74502-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-698-4845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | JERALD LEE SANFORD
-----------------------------------------------------
Credential | EMTP
-----------------------------------------------------
Telephone | 918-698-4845
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------