=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386720159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DALLAS AREA AMBULANCE SERVICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 06/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 E NEWSOM ST
-----------------------------------------------------
City | PRAIRIE FARM
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54762-9714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-455-1575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 E NEWSOM ST
-----------------------------------------------------
City | PRAIRIE FARM
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54762-9714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-455-1575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. ARLENE ELIZABETH GULDVOG
-----------------------------------------------------
Credential | EMT BASIC
-----------------------------------------------------
Telephone | 715-455-1575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 600-1120
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------