Provider Demographics
NPI:1174130074
Name:SHOSHONE COUNTY AMBULANCE SERVICE DISTRICT
Entity type:Organization
Organization Name:SHOSHONE COUNTY AMBULANCE SERVICE DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER - BOARD MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BRANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-752-1101
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:OSBURN
Mailing Address - State:ID
Mailing Address - Zip Code:83849-0488
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58738 SILVER VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:OSBURN
Practice Address - State:ID
Practice Address - Zip Code:83849
Practice Address - Country:US
Practice Address - Phone:208-512-2660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance