MEDICARE: VITALOGY EMS LLC

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	3416L0300X	Land Ambulance

General Provider Information

NPI Number	:	1164190567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALOGY EMS LLC

Provider Business Mailing Address
First Line	:	724 SHADOW LN
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-2340
Country	:	US
Telephone Number	:	406-270-6955
Fax Number	:	406-309-2127

Provider Business Practice Location Address
First Line	:	468 ASH RD
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-2325
Country	:	US
Telephone Number	:	406-270-6955
Fax Number	:	406-309-2127

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BRODIE VERWORN
Credential	:
Telephone Number	:	406-546-1232

Provider Enumeration Date	:	08/31/2021
Last Update Date	:	10/12/2021

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