Basic Information
| Provider Information | |||||||||
| NPI: | 1629437280 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMISSIONER OF ROADS & REVENUE WHEELER COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WHEELER COUNTY EMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 18 NW 3RD AVENUE | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304283730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1252327009 | ||||||||
| FaxNumber: | 9125235600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2016 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOWELL | ||||||||
| AuthorizedOfficialFirstName: | SELENA | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9124239692 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 003176045A | 05 | GA | MEDICAID | 710474800 | 01 | GA | DOL -FECA/ BL / ENERGY | OTHER | N1207418 | 01 | GA | WELLCARE OF GA | OTHER |