MEDICARE: ST. JAMES FIRE DEPARTMENT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance	APPLYING	NC

General Provider Information

NPI Number	:	1639359177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JAMES FIRE DEPARTMENT, INC.

Provider Business Mailing Address
First Line	:	3628 SAINT JAMES DR SE
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-8598
Country	:	US
Telephone Number	:	910-253-9990
Fax Number	:	910-253-9991

Provider Business Practice Location Address
First Line	:	3628 SAINT JAMES DR SE
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-8598
Country	:	US
Telephone Number	:	910-253-9990
Fax Number	:	910-253-9991

Authorized Official
Title or Position	:	PRESIDENT OF BOARD OF DIRECTORS
Name	:	MR. WOODROW F CLOOKIE
Credential	:
Telephone Number	:	910-253-9990

Provider Enumeration Date	:	11/13/2007
Last Update Date	:	04/08/2008

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