=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235323452
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALISADES BONNEVILLE COUNTY RESCUE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2007
-----------------------------------------------------
Last Update Date | 08/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HWY 31 # 15
-----------------------------------------------------
City | SWAN VALLEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-520-7242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 52261
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83405-2261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-523-4906
-----------------------------------------------------
Fax | 208-523-2025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CONNIE JACOBSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-520-7242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 5710
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------