Healthcare Provider Details

I. General information

NPI: 1790186245
Provider Name (Legal Business Name): GOUVERNEUR VOLUNTEER RESCUE SQUAD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 09/15/2014
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

PO BOX 164
GOUVERNEUR NY
13642-0164
US

V. Phone/Fax

Practice location:
  • Phone: 315-287-1321
  • Fax: 315-287-3854
Mailing address:
  • Phone: 315-287-1321
  • Fax: 315-287-3954

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 A DEAVERS
Title or Position: DIRECTOR
Credential:
Phone: 315-287-1321