MEDICARE: BLACK CANYON FIRE DISTRICT

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	121	AZ

General Provider Information

NPI Number	:	1194719997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK CANYON FIRE DISTRICT

Provider Business Mailing Address
First Line	:	PO BOX 967
Second Line	:
City	:	BLACK CANYON CITY
State	:	AZ
Zip	:	85324-0967
Country	:	US
Telephone Number	:	623-374-5512
Fax Number	:	623-374-5513

Provider Business Practice Location Address
First Line	:	35050 S OLD BLACK CANYON HWY
Second Line	:
City	:	BLACK CANYON CITY
State	:	AZ
Zip	:	85324-9771
Country	:	US
Telephone Number	:	623-374-5512
Fax Number	:	623-374-5513

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	JOHN MARK NICHOLS
Credential	:
Telephone Number	:	623-374-5512

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	10/26/2016

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Directions to “BLACK CANYON FIRE DISTRICT ” Practice Location

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