Basic Information
| Provider Information | |||||||||
| NPI: | 1104979368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEMBROKE RESCUE SQUAD, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEMBROKE RESCUE SQUAD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | 564 CANDY PARK RD | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283721306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105212742 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | LOCKLEAR | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 9105212742 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 1192 | NC | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 073CH | 01 | NC | BLUECROSS/BLUESHIELD NC | OTHER |