Provider Demographics
NPI:1194719997
Name:BLACK CANYON FIRE DISTRICT
Entity type:Organization
Organization Name:BLACK CANYON FIRE DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-374-5512
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:BLACK CANYON CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85324-0967
Mailing Address - Country:US
Mailing Address - Phone:623-374-5512
Mailing Address - Fax:623-374-5513
Practice Address - Street 1:35050 S OLD BLACK CANYON HWY
Practice Address - Street 2:
Practice Address - City:BLACK CANYON CITY
Practice Address - State:AZ
Practice Address - Zip Code:85324-9771
Practice Address - Country:US
Practice Address - Phone:623-374-5512
Practice Address - Fax:623-374-5513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1213416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ65426Medicare PIN
AZZ65426Medicare PIN