=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538338801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOTTINEAU AMBULANCE SERVICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2008
-----------------------------------------------------
Last Update Date | 02/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 BENNETT ST
-----------------------------------------------------
City | BOTTINEAU
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-228-3669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1310 THOMPSON ST
-----------------------------------------------------
City | BOTTINEAU
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58318-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-228-3669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | ALAN THOMAS OMVIG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 701-228-3669
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 0014
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------