Provider Demographics
NPI:1386720159
Name:DALLAS AREA AMBULANCE SERVICE
Entity type:Organization
Organization Name:DALLAS AREA AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GULDVOG
Authorized Official - Suffix:
Authorized Official - Credentials:EMT BASIC
Authorized Official - Phone:715-455-1575
Mailing Address - Street 1:210 E NEWSOM ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE FARM
Mailing Address - State:WI
Mailing Address - Zip Code:54762-9714
Mailing Address - Country:US
Mailing Address - Phone:715-455-1575
Mailing Address - Fax:
Practice Address - Street 1:210 E NEWSOM ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE FARM
Practice Address - State:WI
Practice Address - Zip Code:54762-9714
Practice Address - Country:US
Practice Address - Phone:715-455-1575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI600-11203416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41333400Medicaid
WI41333400Medicaid