Provider Demographics
NPI:1730184631
Name:COMSTOCK RURAL FIRE DEPARTMENT AMBULANCE
Entity type:Organization
Organization Name:COMSTOCK RURAL FIRE DEPARTMENT AMBULANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-628-4340
Mailing Address - Street 1:403 CHATHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:NE
Mailing Address - Zip Code:68814
Mailing Address - Country:US
Mailing Address - Phone:308-935-1569
Mailing Address - Fax:308-935-1569
Practice Address - Street 1:45989 HIGHWAY S21C
Practice Address - Street 2:
Practice Address - City:COMSTOCK
Practice Address - State:NE
Practice Address - Zip Code:68828-5134
Practice Address - Country:US
Practice Address - Phone:308-215-0254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1074341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE09365OtherBLUECROSS
NE10024985500Medicaid
NE099290Medicare ID - Type Unspecified