=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174679906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY OF MOUNDRIDGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 11/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 N WEDEL AVE
-----------------------------------------------------
City | MOUNDRIDGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67107-7540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-345-3657
-----------------------------------------------------
Fax | 620-345-3665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 N WEDEL AVE
-----------------------------------------------------
City | MOUNDRIDGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67107-7540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-345-3657
-----------------------------------------------------
Fax | 620-345-3665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING
-----------------------------------------------------
Name | ANGIE VICKREY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 620-345-3657
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 1350
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------