South Park Ambulance District
Organization Active NPI Land Ambulance · Fairplay, CO
NPI 1811091051 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1811091051
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Land Ambulance 3416L0300X
- Legal business name
- SOUTH PARK AMBULANCE DISTRICT
- Practice address
- 911 Castello Avenue
Fairplay, CO 80440 - Phone
- (719) 836-2055
- NPI assigned
- Sep 8, 2006
- Organization subpart
- No
Authorized official
- Name
- Lissa Mattson
- Title
- Chief Administrative Officer
- Phone
- (719) 836-2055
Practitioners 1
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 06D0698408 | South Park Ambulance District | Certificate of waiver | Aug 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CO
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050919000240 | CO | Part B Supplier - Ambulance Service Supplier | 2769415827 | Practice locations: Fairplay, CO |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Land Ambulance | 3416L0300X | Yes |
Addresses
Primary practice location
911 Castello Avenue
Fairplay, CO 80440
Mailing address
911 Castello Avenue
Fairplay, CO 80440
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 06000442 | Medicaid | CO |
Other providers in Fairplay, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.