Provider Demographics
NPI:1124096680
Name:PORT BOLIVAR VFN & EMS
Entity type:Organization
Organization Name:PORT BOLIVAR VFN & EMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-397-0397
Mailing Address - Street 1:PO BOX 691363
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77269-1363
Mailing Address - Country:US
Mailing Address - Phone:281-397-0397
Mailing Address - Fax:281-397-0007
Practice Address - Street 1:1806 LOOP 108
Practice Address - Street 2:
Practice Address - City:PORT BOLIVAR
Practice Address - State:TX
Practice Address - Zip Code:77650
Practice Address - Country:US
Practice Address - Phone:409-684-1984
Practice Address - Fax:409-684-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00083263OtherRAILROAD MEDICARE
TX000555501Medicaid
LA1635626Medicaid
TX517858Medicare ID - Type Unspecified
TX000555501Medicaid