Basic Information
| Provider Information | |||||||||
| NPI: | 1336148170 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRY FORK SQUAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006764785 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | ROUTE 16 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAR | ||||||||
| State: | WV | ||||||||
| PostalCode: | 24892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048752230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | HICKS | ||||||||
| AuthorizedOfficialFirstName: | SHEREE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3048752230 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | WV | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 0145171000 | 05 | WV | MEDICAID |