1629388350 NPI number — STAR CITY VOLUNTEER FIRE DEPT INC

Table of content: (NPI 1629388350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629388350 NPI number — STAR CITY VOLUNTEER FIRE DEPT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAR CITY VOLUNTEER FIRE DEPT 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:
1629388350
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4235
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAR CITY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26504-4235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-599-1539
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3384 UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAR CITY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-599-1539
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GOODWIN
Authorized Official First Name:
DONNIE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
HEAD TRUSTEE
Authorized Official Telephone Number:
304-599-1539

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3810020145 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002575397 . This is a "HIGHMARK WEST VIRGINIA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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