Basic Information
| Provider Information | |||||||||
| NPI: | 1295872018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLAY COUNTY AMBULANCE SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLAY COUNTY AMBULANCE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 BROOKS ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043452312 | ||||||||
| FaxNumber: | 3043525316 | ||||||||
| Practice Location | |||||||||
| Address1: | 464 MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | CLAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045872554 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HARMON | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3043452312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | WV | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 001705377 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 0145262000 | 05 | WV | MEDICAID |