Healthcare Provider Details

I. General information

NPI: 1073890489
Provider Name (Legal Business Name): LAKE WACCAMAW FIRE & RESCUE SQUAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 FLEMINGTON DR.
LAKE WACCAMAW NC
28450-0000
US

IV. Provider business mailing address

PO BOX 7
LAKE WACCAMAW NC
28450-0007
US

V. Phone/Fax

Practice location:
  • Phone: 910-646-4441
  • Fax:
Mailing address:
  • Phone: 910-646-1070
  • Fax: 910-646-1071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number1483
License Number StateNC

VIII. Authorized Official

Name: CHARLES S WORRELL
Title or Position: CHIEF
Credential:
Phone: 910-646-1070