MEDICARE: SUGAR GROVE LIFESAVING CREW 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

General Provider Information

NPI Number	:	1972178994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUGAR GROVE LIFESAVING CREW INC

Provider Business Mailing Address
First Line	:	PO BOX 3348
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29304-3348
Country	:	US
Telephone Number	:	866-764-4911
Fax Number	:

Provider Business Practice Location Address
First Line	:	178 FLAT RIDGE RD
Second Line	:
City	:	SUGAR GROVE
State	:	VA
Zip	:	24375
Country	:	US
Telephone Number	:	276-677-3494
Fax Number	:

Authorized Official
Title or Position	:	CAPTAIN
Name	:	DAVID M LINEBERRY
Credential	:
Telephone Number	:	276-233-2682

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	05/27/2022

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