Basic Information
| Provider Information | |||||||||
| NPI: | 1154396406 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOWN OF CARROLL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TWIN MOUNTAIN FIRE RESCUE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 100 SCHOOL STREET | ||||||||
| Address2: | |||||||||
| City: | TWIN MOUNTAIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038465545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLESON | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 6038465545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 30851814 | 05 | NH | MEDICAID | 71Y002254NH01 | 01 | ANTHEM BCBS | OTHER | Z34827 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 702524 | 01 | HARVARD PILGRIM | OTHER | 710580900 | 01 | NH | DOL - FECA/ BL/ ENERGY | OTHER | 590014897 | 01 | RR MEDICARE | OTHER | 804220 | 01 | TUFTS HEALTH PLAN | OTHER |