Provider Demographics
NPI:1154411676
Name:MOHALL AMBULANCE SERVICE
Entity type:Organization
Organization Name:MOHALL AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-756-7156
Mailing Address - Street 1:105 MAIN ST WEST
Mailing Address - Street 2:
Mailing Address - City:MOHALL
Mailing Address - State:ND
Mailing Address - Zip Code:58761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 MAIN ST WEST
Practice Address - Street 2:
Practice Address - City:MOHALL
Practice Address - State:ND
Practice Address - Zip Code:58761
Practice Address - Country:US
Practice Address - Phone:701-756-7159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND089341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND7021OtherBLUE CROSS BLUE SHIELD
ND59006107OtherRAILROAD MEDICARE
ND56732Medicaid
ND56732Medicaid