Basic Information
| Provider Information | |||||||||
| NPI: | 1881693166 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHORT GAP VOLUNTEER FIRE COMPANY | ||||||||
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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: | 128 KNOBLEY ROAD | ||||||||
| Address2: | |||||||||
| City: | RIDGELEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047264388 | ||||||||
| FaxNumber: | 3047264521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 05/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | TRENTER | ||||||||
| AuthorizedOfficialFirstName: | LAUREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 3047264388 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | WV | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 323321 | 01 | VA | BLUE CROSS | OTHER | 409664900 | 05 | MD | MEDICAID | 590014173 | 01 | WV | RAILROAD MEDICARE | OTHER | 001705368 | 01 | WV | BLUE CROSS | OTHER | 8005010000 | 05 | WV | MEDICAID |