Basic Information
| Provider Information | |||||||||
| NPI: | 1942486766 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUNTAIN VOLUNTEER FIRE COMPANY INC | ||||||||
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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: | RT. 46 EAST | ||||||||
| Address2: | |||||||||
| City: | KEYSER | ||||||||
| State: | WV | ||||||||
| PostalCode: | 267260056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047884071 | ||||||||
| FaxNumber: | 3047884071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2008 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3045211576 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 62952 | WV | N | Transportation Services | Ambulance | 341600000X | WVEMS | WV | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | P00477560 | 01 | WV | RAILROAD MEDICARE | OTHER | 002032962 | 01 | WV | BCBS | OTHER | 3810011664 | 05 | WV | MEDICAID | 002032962 | 01 | WV | BLUE CROSS | OTHER |