=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275687386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELBY VOLUNTEER AMBULANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 04/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2511 3RD AVE
-----------------------------------------------------
City | SELBY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57472-0192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-649-7362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 192
-----------------------------------------------------
City | SELBY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57472-0192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | SHARON MOAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-649-7362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 632
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------