=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336644681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CASCADES COMMUNITY SERVICES DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2018
-----------------------------------------------------
Last Update Date | 03/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 ASH VALLEY RD.
-----------------------------------------------------
City | ADIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96006-0239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-299-3110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 239
-----------------------------------------------------
City | ADIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96006-0239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-299-3110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DISTRICT MANAGGER
-----------------------------------------------------
Name | MR. ERNEST DANIEL BOUSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-299-3110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------