MEDICARE: PORT BOLIVAR VFN & EMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	341600000X	Ambulance		TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00083263	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124096680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT BOLIVAR VFN & EMS

Provider Business Mailing Address
First Line	:	PO BOX 691363
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77269-1363
Country	:	US
Telephone Number	:	281-397-0397
Fax Number	:	281-397-0007

Provider Business Practice Location Address
First Line	:	1806 LOOP 108
Second Line	:
City	:	PORT BOLIVAR
State	:	TX
Zip	:	77650
Country	:	US
Telephone Number	:	409-684-1984
Fax Number	:	409-684-1984

Authorized Official
Title or Position	:	AUTHORIZED AGENT
Name	:	KAREN LAAKE
Credential	:
Telephone Number	:	281-397-0397

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	07/02/2008

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Directions to “PORT BOLIVAR VFN & EMS ” Practice Location

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