Basic Information
| Provider Information | |||||||||
| NPI: | 1841273257 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEE COUNTY FISCAL COURT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CITIZENS OF LEE COUNTY AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045211576 | ||||||||
| FaxNumber: | 3045211768 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 WALNUT STREET | ||||||||
| Address2: | |||||||||
| City: | BEATTYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064649288 | ||||||||
| FaxNumber: | 6064644145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 04/04/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3045211576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 1202 | KY | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 590587046 | 01 | KY | RAILROAD MEDICARE ID NO. | OTHER | 000000070476 | 01 | KY | ANTHEM BC BS | OTHER | 000000070476 | 01 | KY | ANTHEM | OTHER | 55065015 | 05 | KY | MEDICAID | 56003726 | 05 | KY | MEDICAID |