Basic Information
Provider Information | |||||||||
NPI: | 1073512414 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MJS ENTERPRISES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST JOSEPHS AMBULANCE SERVICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 836 4TH AVE | ||||||||
Address2: |   | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257011407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8006764785 | ||||||||
FaxNumber: | 3045224222 | ||||||||
Practice Location | |||||||||
Address1: | 1619 SAINT MARYS AVE | ||||||||
Address2: |   | ||||||||
City: | PARKERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 261013346 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044244670 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2005 | ||||||||
LastUpdateDate: | 03/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEEKLEY | ||||||||
AuthorizedOfficialFirstName: | DWANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
AuthorizedOfficialTelephone: | 3044244670 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X |   | WV | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 55001333 | 05 | KY |   | MEDICAID | 080051800 | 01 | WV | BLACK LUNG | OTHER | P00046067 | 01 | WV | RAILROAD MEDICARE | OTHER | 001705619 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 2439721 | 05 | OH |   | MEDICAID | 8003072000 | 05 | WV |   | MEDICAID | 612941100 | 01 | WV | FEDERAL DEPT OF LABOR | OTHER |