Healthcare Provider Details

I. General information

NPI: 1265488746
Provider Name (Legal Business Name): WILLIE GOSS AMBULANCE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 N JACKSON ST
KOSCIUSKO MS
39090-3130
US

IV. Provider business mailing address

PO BOX 303
KOSCIUSKO MS
39090-0303
US

V. Phone/Fax

Practice location:
  • Phone: 662-289-1523
  • Fax: 662-289-1597
Mailing address:
  • Phone: 662-289-1523
  • Fax: 662-289-1597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number318
License Number StateMS

VIII. Authorized Official

Name: WILLIE GOSS
Title or Position: PRESIDENT
Credential:
Phone: 662-289-1523