Provider Demographics
NPI:1730145731
Name:CITY OF GOTHENBURG
Entity type:Organization
Organization Name:CITY OF GOTHENBURG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASST. RESCUE CAPTAIN
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:531-895-5853
Mailing Address - Street 1:10802 FARNAM DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-3237
Mailing Address - Country:US
Mailing Address - Phone:877-218-4392
Mailing Address - Fax:877-343-0131
Practice Address - Street 1:610 10TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-2013
Practice Address - Country:US
Practice Address - Phone:402-572-4019
Practice Address - Fax:402-965-8594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11323416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE826590178OtherRAILROAD MEDICARE NO
NE09442OtherBLUE CROSS BLUE SHIELD PR
NE09442OtherBLUE CROSS BLUE SHIELD PR