=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689778391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEADOW VALLEY AMBULANCE SERVICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 01/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 HWY 95
-----------------------------------------------------
City | NEW MEADOWS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-347-3190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 532
-----------------------------------------------------
City | NEW MEADOWS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83654-0532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-469-0005
-----------------------------------------------------
Fax | 208-347-3190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EMS CHIEF
-----------------------------------------------------
Name | JACOB MAC QUALLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-469-0005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | #5313
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------