Basic Information
| Provider Information | |||||||||
| NPI: | 1487961447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAVERLY RESCUE SQUAD, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707448413 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 BANK STREET | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048342835 | ||||||||
| FaxNumber: | 8048343116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2010 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | MEYERS | ||||||||
| AuthorizedOfficialFirstName: | BONITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 4074633087 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | VA | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 710485000 | 01 | VA | DOL - FECA/ BL/ ENERGY | OTHER | 1487961447 | 05 | VA | MEDICAID |