1104996040 NPI number — GRAND ISLE VOLUNTEER EMERGENCY SERVICES, INC

Table of content: (NPI 1104996040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104996040 NPI number — GRAND ISLE VOLUNTEER EMERGENCY SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND ISLE VOLUNTEER EMERGENCY SERVICES, 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:
G.I.V.E.S.
Provider Other Organization Name Type Code:
5
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:
1104996040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SLIPPERY ROCK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16057-0776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-280-5974
Provider Business Mailing Address Fax Number:
724-794-1633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 CHIGHIZOLA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND ISLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70538-1035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-787-2777
Provider Business Practice Location Address Fax Number:
724-794-1633
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRADBERRY
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
985-787-2777

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  MT0004185 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1667471 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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