Basic Information
Provider Information | |||||||||
NPI: | 1235138090 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FORK RIDGE COMMUNITY VOLUNTEER FIRE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FORK RIDGE VFD | ||||||||
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: | 3045211576 | ||||||||
FaxNumber: | 3045211768 | ||||||||
Practice Location | |||||||||
Address1: | 354 SAWMILL LN | ||||||||
Address2: |   | ||||||||
City: | GLEN EASTON | ||||||||
State: | WV | ||||||||
PostalCode: | 260391547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3048453990 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2005 | ||||||||
LastUpdateDate: | 06/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHEELER | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3045211576 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | WV0EMS | WV | N |   | Transportation Services | Ambulance |   | 341600000X |   | WV | N |   | Transportation Services | Ambulance |   | 3416L0300X | WV0EMS | WV | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 225257 | 01 | WV | CARELINK | OTHER | 001705594 | 01 | WV | BLUE CROSS | OTHER | 2516601 | 05 | OH |   | MEDICAID | 8002019000 | 05 | WV |   | MEDICAID | 590014570 | 01 | WV | RAILROAD MEDICARE | OTHER |