Provider Demographics
NPI:1962574848
Name:PORTAL AMBULANCE
Entity type:Organization
Organization Name:PORTAL AMBULANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SQUAD LEADER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KNUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-I85
Authorized Official - Phone:701-933-2878
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:PORTAL
Mailing Address - State:ND
Mailing Address - Zip Code:58752-0061
Mailing Address - Country:US
Mailing Address - Phone:701-933-2878
Mailing Address - Fax:
Practice Address - Street 1:301 CLARK ST
Practice Address - Street 2:
Practice Address - City:PORTAL
Practice Address - State:ND
Practice Address - Zip Code:58772
Practice Address - Country:US
Practice Address - Phone:701-839-6326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1053416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND50505Medicaid
ND590013588OtherRAILROAD MEDICARE
ND7409OtherBLUE CROSS BLUE SHIELD
N71147Medicare PIN