Basic Information
| Provider Information | |||||||||
| NPI: | 1538206693 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAVALETTE VOLUNTEER FIRE DEPT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 836 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045227533 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 4502 ROUTE 152 | ||||||||
| Address2: | |||||||||
| City: | LAVALETTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257156 | ||||||||
| FaxNumber: | 3045252829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 12/01/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3045227533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | N | Transportation Services | Ambulance | Land Transport | 341600000X | WV | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 0145904000 | 05 | WV | MEDICAID | 590013929 | 01 | WV | RAILROAD MEDICARE | OTHER |