1093765976 NPI number — PRINCE EDWARD VOLUNTEER RESCUE SQUAD, INC

Table of content: (NPI 1093765976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093765976 NPI number — PRINCE EDWARD VOLUNTEER RESCUE SQUAD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRINCE EDWARD VOLUNTEER RESCUE SQUAD, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093765976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 863
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27023-0863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-392-6973
Provider Business Mailing Address Fax Number:
434-392-7525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 DOSWELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-392-6973
Provider Business Practice Location Address Fax Number:
434-392-7525
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
DEANNA
Authorized Official Middle Name:
WAGSTAFF
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
434-392-6973

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  170 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009012061 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 432775 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 34725 . This is a "OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 590014004 . This is a "RR M CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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