Basic Information
Provider Information | |||||||||
NPI: | 1710950704 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CANNON COUNTY AMBULANCE SERVICE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9150 | ||||||||
Address2: |   | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420029150 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707449600 | ||||||||
FaxNumber: | 2707448642 | ||||||||
Practice Location | |||||||||
Address1: | 104 ALEXANDER DR | ||||||||
Address2: |   | ||||||||
City: | WOODBURY | ||||||||
State: | TN | ||||||||
PostalCode: | 371905275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6155635959 | ||||||||
FaxNumber: | 6155636878 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2006 | ||||||||
LastUpdateDate: | 06/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | JUSTIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6156532655 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X |   |   | N |   | Transportation Services | Ambulance |   | 3416L0300X |   |   | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 2007454 | 01 | TN | TENN CARE NON EMERGENCY | OTHER | 4110424 | 01 | TN | TENN CARE EMERGENCY | OTHER | 4110424 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 3525445 | 05 | TN |   | MEDICAID |