Provider Demographics
NPI:1609926013
Name:CITY OF ELLENDALE
Entity type:Organization
Organization Name:CITY OF ELLENDALE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:ERWIN
Authorized Official - Last Name:GULKE
Authorized Official - Suffix:
Authorized Official - Credentials:NREMT-P
Authorized Official - Phone:701-349-3364
Mailing Address - Street 1:PO BOX 267
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:ND
Mailing Address - Zip Code:58436-0267
Mailing Address - Country:US
Mailing Address - Phone:701-349-3364
Mailing Address - Fax:701-349-3333
Practice Address - Street 1:55 3RD AVE S
Practice Address - Street 2:
Practice Address - City:ELLENDALE
Practice Address - State:ND
Practice Address - Zip Code:58436
Practice Address - Country:US
Practice Address - Phone:701-349-3364
Practice Address - Fax:701-349-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND333416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2955-001OtherBC-BS PROVIDER
ND590095437OtherRAILROAD MEDICARE PROVIDE
ND52179Medicaid
SD9010790OtherSD MEDICAID PROVIDER
ND52179Medicaid
ND2955-001OtherBC-BS PROVIDER