Provider Demographics
NPI:1104002922
Name:FORT BELKNAP EMERGENCY MEDICAL SERVICES
Entity type:Organization
Organization Name:FORT BELKNAP EMERGENCY MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:UNGARETTI
Authorized Official - Suffix:
Authorized Official - Credentials:CCEMTP
Authorized Official - Phone:406-549-7104
Mailing Address - Street 1:1008 BURLINGTON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5681
Mailing Address - Country:US
Mailing Address - Phone:406-549-7104
Mailing Address - Fax:406-542-2785
Practice Address - Street 1:RR 1 BOX 67
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:MT
Practice Address - Zip Code:59526-9705
Practice Address - Country:US
Practice Address - Phone:406-549-7104
Practice Address - Fax:406-542-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTT-05.28PCN344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0540532Medicaid