Basic Information
| Provider Information | |||||||||
| NPI: | 1497116909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENOVO FIRE DEPARTMENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 11TH ST | ||||||||
| Address2: | |||||||||
| City: | RENOVO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177641121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709231446 | ||||||||
| FaxNumber: | 5709230210 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 11TH ST | ||||||||
| Address2: | |||||||||
| City: | RENOVO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177641121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709231446 | ||||||||
| FaxNumber: | 5709230210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2016 | ||||||||
| LastUpdateDate: | 02/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5709231446 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 1031158650001 | 05 | PA | MEDICAID |