Provider Demographics
NPI:1902965627
Name:CITY OF STEPHEN
Entity Type:Organization
Organization Name:CITY OF STEPHEN
Other - Org Name:STEPHEN VOLUNTEER AMBULANCE SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:CITY CLERK
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-478-3614
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:
Mailing Address - City:STEPHEN
Mailing Address - State:MN
Mailing Address - Zip Code:56757-0630
Mailing Address - Country:US
Mailing Address - Phone:218-478-3614
Mailing Address - Fax:218-478-3806
Practice Address - Street 1:846 5TH STREET
Practice Address - Street 2:
Practice Address - City:STEPHEN
Practice Address - State:MN
Practice Address - Zip Code:56757-0289
Practice Address - Country:US
Practice Address - Phone:218-478-3864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF STEPHEN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-08
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN177413416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN170709OtherBLUE CROSS BLUE SHIELD-MN
MN093867000Medicaid
MN599000217Medicare ID - Type Unspecified