=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982727988
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF GOODING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2007
-----------------------------------------------------
Last Update Date | 02/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 7TH AVE E
-----------------------------------------------------
City | GOODING
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83330-1660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-934-4015
-----------------------------------------------------
Fax | 208-934-5260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 417
-----------------------------------------------------
City | GOODING
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83330-0417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-934-4015
-----------------------------------------------------
Fax | 208-934-5260
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EMS DIRECTOR
-----------------------------------------------------
Name | MRS. DENISE GILL
-----------------------------------------------------
Credential | EMT-A
-----------------------------------------------------
Telephone | 208-934-4841
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 7504
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------