=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336142371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY OF MEDFORD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 N FRONT ST
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73759-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-395-2823
-----------------------------------------------------
Fax | 580-395-3122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 123
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-395-2823
-----------------------------------------------------
Fax | 580-395-3122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | OMA LEA ROGERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-395-2823
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | EMS036
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------