Basic Information
| Provider Information | |||||||||
| NPI: | 1285854307 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPON BRIDGE RESCUE SQUAD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045227533 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | US ROUTE 50 | ||||||||
| Address2: | |||||||||
| City: | CAPON BRIDGE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 267110265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048563109 | ||||||||
| FaxNumber: | 3048563109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3045227533 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | WV EMS | WV | N | Transportation Services | Ambulance | 341600000X | WV | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 083237400 | 01 | WV | BLACK LUNG | OTHER | 590009398 | 01 | WV | RAILROAD MEDICARE | OTHER | 001705463 | 01 | WV | BLUE CROSS/BLUE SHIELD | OTHER | 0144690000 | 05 | WV | MEDICAID |