Basic Information
| Provider Information | |||||||||
| NPI: | 1922386846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MATTAPONI VOLUNTEER RESCUE SQUAD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707448413 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | 6089 CATEBURY ROAD | ||||||||
| Address2: | |||||||||
| City: | WALKERTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047693487 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2011 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | MASON | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8049370764 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 799 | VA | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 1922386846 | 05 | KY | MEDICAID |