Healthcare Provider Details

I. General information

NPI: 1578520318
Provider Name (Legal Business Name): LEFT BEAVER CIVIL DEFENSE & RESCUE SQUAD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15990 KY HWY 122
HI HAT KY
41636
US

IV. Provider business mailing address

PO BOX 396
MCDOWELL KY
41647
US

V. Phone/Fax

Practice location:
  • Phone: 606-377-6643
  • Fax: 606-377-2888
Mailing address:
  • Phone: 606-377-6643
  • Fax: 606-377-2888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number1403
License Number StateKY

VIII. Authorized Official

Name: MR. SHANNON TODD HALL
Title or Position: EMS DIRECTOR
Credential:
Phone: 606-377-6643