Healthcare Provider Details

I. General information

NPI: 1932199148
Provider Name (Legal Business Name): CANYON LAKE FIRE/EMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 04/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 SATTLER RD
CANYON LAKE TX
78132-2213
US

IV. Provider business mailing address

PO BOX 2140
CANYON LAKE TX
78133-0024
US

V. Phone/Fax

Practice location:
  • Phone: 830-907-2922
  • Fax: 830-907-2408
Mailing address:
  • Phone: 830-907-2922
  • Fax: 830-907-2408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number046001
License Number StateTX

VIII. Authorized Official

Name: MR. SHAWN MICHAEL WHERRY
Title or Position: CHIEF
Credential: FF/EMT-P
Phone: 830-907-2922