Basic Information
| Provider Information | |||||||||
| NPI: | 1700886504 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHADY GROVE VOLUNTEER FIRE AND RESCUE DEPARTMENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006764785 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 SHADY GROVE DR | ||||||||
| Address2: | |||||||||
| City: | THAXTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241742902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408907484 | ||||||||
| FaxNumber: | 5408902290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 12/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | WRAY | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 5408907484 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 1002 | VA | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 010142091 | 05 | VA | MEDICAID | P00208310 | 01 | VA | RAILROAD MEDICARE | OTHER | 178077 | 01 | VA | BLUE CROSS | OTHER |