Basic Information
| Provider Information | |||||||||
| NPI: | 1730194572 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEAVER FIRE SERVICE DISTRICT 1 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BEAVER VALLEY AMBULANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | BEAVER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847130549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4354387151 | ||||||||
| FaxNumber: | 4354387166 | ||||||||
| Practice Location | |||||||||
| Address1: | 1090 N MAIN | ||||||||
| Address2: | |||||||||
| City: | BEAVER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847130549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4354387151 | ||||||||
| FaxNumber: | 4354387166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 02/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YARDLEY | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4354387151 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BEAVER FIRE SERVICE DISTRICT 1 | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 0101L | UT | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 990002018001 | 05 | UT | MEDICAID |