Provider Demographics
NPI:1811091051
Name:SOUTH PARK AMBULANCE DISTRICT
Entity type:Organization
Organization Name:SOUTH PARK AMBULANCE DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-836-2055
Mailing Address - Street 1:911 CASTELLO AVENUE
Mailing Address - Street 2:
Mailing Address - City:FAIRPLAY
Mailing Address - State:CO
Mailing Address - Zip Code:80440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:911 CASTELLO AVENUE
Practice Address - Street 2:
Practice Address - City:FAIRPLAY
Practice Address - State:CO
Practice Address - Zip Code:80440
Practice Address - Country:US
Practice Address - Phone:719-836-2055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06000442Medicaid
CO06000442Medicaid