1578520318 NPI number — LEFT BEAVER CIVIL DEFENSE & RESCUE SQUAD, INC.

Table of content: (NPI 1578520318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578520318 NPI number — LEFT BEAVER CIVIL DEFENSE & RESCUE SQUAD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEFT BEAVER CIVIL DEFENSE & 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:
LEFT BEAVER RESCUE SQUAD
Provider Other Organization Name Type Code:
3
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:
1578520318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 396
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDOWELL
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-377-6643
Provider Business Mailing Address Fax Number:
606-377-2888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15990 KY HWY 122
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HI HAT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-377-6643
Provider Business Practice Location Address Fax Number:
606-377-2888
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
TODD
Authorized Official Title or Position:
EMS DIRECTOR
Authorized Official Telephone Number:
606-377-6643

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  1403 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 56005457 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2588650 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55036065 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 089857100 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 590008357 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000070497 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1264125 . This is a "UNITED MINE WORKERS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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