Basic Information
| Provider Information | |||||||||
| NPI: | 1437147808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RESCUE SQUAD OF CLIFTON FORGE VA., INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLIFTON FORGE RESCUE SQUAD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045227533 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 522 COMMERCIAL AVE. | ||||||||
| Address2: | |||||||||
| City: | CLIFTON FORGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409699708 | ||||||||
| FaxNumber: | 5408623354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8006764785 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 229 | VA | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 010211204 | 05 | VA | MEDICAID | P00228595 | 01 | VA | RAILROAD MEDICARE | OTHER | 188850 | 01 | VA | BLUE CROSS VA | OTHER | 188850 | 01 | VA | ANTHEM | OTHER |