Basic Information
| Provider Information | |||||||||
| NPI: | 1508022690 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRAIG COUNTY - PAINT BANK VOLUNTEER FIRE COMPANY AND RESCUE SQUAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045211576 | ||||||||
| FaxNumber: | 3045211768 | ||||||||
| Practice Location | |||||||||
| Address1: | 15998 PAINT BANK ROAD | ||||||||
| Address2: | |||||||||
| City: | PAINT BANK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408975200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2008 | ||||||||
| LastUpdateDate: | 10/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3045211576 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 510 | VA | N | Transportation Services | Ambulance | Land Transport | 341600000X | 510 | VA | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 1508022690 | 05 | VA | MEDICAID | 3810014404 | 05 | WV | MEDICAID |