Healthcare Provider Details

I. General information

NPI: 1245228782
Provider Name (Legal Business Name): GOUVERNEUR VOLUNTEER RESCUE SQUAD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 US HIGHWAY 11
GOUVERNEUR NY
13642-3507
US

IV. Provider business mailing address

892 NEW CASTLE RD
SLIPPERY ROCK PA
16057-4228
US

V. Phone/Fax

Practice location:
  • Phone: 315-287-1321
  • Fax: 315-287-3954
Mailing address:
  • Phone: 800-280-5974
  • Fax: 724-794-1633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number4417
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number43946
License Number StateNY

VIII. Authorized Official

Name: MR. MARK DEAVERS
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 315-287-1321