=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558440669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBBY VOLUNTEER AMBULANCE SERVICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2006
-----------------------------------------------------
Last Update Date | 03/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 307 MONTANA AVE
-----------------------------------------------------
City | LIBBY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59923-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-293-5582
-----------------------------------------------------
Fax | 406-293-6868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 307 MONTANA AVE
-----------------------------------------------------
City | LIBBY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59923-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-293-5582
-----------------------------------------------------
Fax | 406-293-6868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | PENNY DEAN KYES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-293-5582
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 021
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------