MEDICARE: LAKE MOHAVE RANCHOS 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	07447537Z	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	166927	OTHER	AZ	AHCCCS PROVIDER NO.

General Provider Information

NPI Number	:	1861420929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE MOHAVE RANCHOS FIRE DISTRICT

Provider Business Mailing Address
First Line	:	PO BOX 611
Second Line	:
City	:	DOLAN SPRINGS
State	:	AZ
Zip	:	86441-0611
Country	:	US
Telephone Number	:	928-767-3300
Fax Number	:	928-767-3301

Provider Business Practice Location Address
First Line	:	16126 PIERCE FERRY RD.
Second Line	:
City	:	DOLAN SPRINGS
State	:	AZ
Zip	:	86441-0611
Country	:	US
Telephone Number	:	928-767-3300
Fax Number	:	928-767-3301

Authorized Official
Title or Position	:	SECRETARY
Name	:	ELLEN REH
Credential	:
Telephone Number	:	928-767-3300

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	01/13/2012

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