Healthcare Provider Details

I. General information

NPI: 1437145414
Provider Name (Legal Business Name): TIDIOUTE AREA VOLUNTEER FIRE DEPT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 MAIN ST
TIDIOUTE PA
16351-1109
US

IV. Provider business mailing address

PO BOX 207
ALLENTOWN PA
18105-0207
US

V. Phone/Fax

Practice location:
  • Phone: 814-484-3555
  • Fax: 814-484-1781
Mailing address:
  • Phone: 484-664-2007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number03266
License Number StatePA

VIII. Authorized Official

Name: JOHN W FULLERMAN JR.
Title or Position: COORDINATOR
Credential: EMT
Phone: 814-484-2212