Healthcare Provider Details

I. General information

NPI: 1386773091
Provider Name (Legal Business Name): SAMSON VOL. RESCUE SQUAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 S RIPLEY ST
SAMSON AL
36477-1410
US

IV. Provider business mailing address

P O BOX 22
SAMSON AL
36477
US

V. Phone/Fax

Practice location:
  • Phone: 334-898-1153
  • Fax: 334-898-1153
Mailing address:
  • Phone: 334-898-1183
  • Fax: 334-898-1153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number471
License Number StateAL

VIII. Authorized Official

Name: GARY WIGINTON
Title or Position: CAPTIAN
Credential: EMR
Phone: 334-898-2471