Provider Demographics
NPI:1306097282
Name:MAYBELL VOLUNTEER AMBULANCE
Entity type:Organization
Organization Name:MAYBELL VOLUNTEER AMBULANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:801-295-9886
Mailing Address - Street 1:221 WEST VICTORY WAY
Mailing Address - Street 2:STE 110
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625
Mailing Address - Country:US
Mailing Address - Phone:970-272-3209
Mailing Address - Fax:
Practice Address - Street 1:314 COLLAM STREET
Practice Address - Street 2:
Practice Address - City:MAYBELL
Practice Address - State:CO
Practice Address - Zip Code:81640
Practice Address - Country:US
Practice Address - Phone:970-824-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO200656341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO506938Medicare PIN