Provider Demographics
NPI:1871719914
Name:BERTHOLD AMBULANCE SERVICES
Entity type:Organization
Organization Name:BERTHOLD AMBULANCE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TRES
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEGENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-721-7316
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:BERTHOLD
Mailing Address - State:ND
Mailing Address - Zip Code:58718
Mailing Address - Country:US
Mailing Address - Phone:701-721-7316
Mailing Address - Fax:701-453-3299
Practice Address - Street 1:15 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:BERTHOLD
Practice Address - State:ND
Practice Address - Zip Code:58718
Practice Address - Country:US
Practice Address - Phone:701-721-7316
Practice Address - Fax:701-453-3299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND0063416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND590015360OtherRAILROAD MEDICAL PROVIDER
ND52290Medicaid
ND7532OtherND BLUE CROSS BLUE SHIELD
ND52290Medicaid
ND7532Medicare PIN