Basic Information
| Provider Information | |||||||||
| NPI: | 1639472855 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | S P ACQUISITION CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | GRANDVIEW AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707440834 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 HIGHWAY 28 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373473638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238379500 | ||||||||
| FaxNumber: | 4238373230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2010 | ||||||||
| LastUpdateDate: | 02/18/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANDONKELAAR | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6157643048 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | S P ACQUISITION CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 1234567 | TN | Y | Transportation Services | Ambulance |
No ID Information.