Basic Information
| Provider Information | |||||||||
| NPI: | 1275516189 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TUCKER COUNTY EMERGENCY AMBULANCE SERVICE AUTHORITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | PARSONS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262871046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044782296 | ||||||||
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| Practice Location | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006764785 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 3044782296 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | WVEMS | WV | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 0145548000 | 05 | WV | MEDICAID |