Healthcare Provider Details

I. General information

NPI: 1598719734
Provider Name (Legal Business Name): ALTAVISTA LIFE SAVING AND FIRST AID CREW, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 MAIN ST
ALTAVISTA VA
24517
US

IV. Provider business mailing address

PO BOX 1 1510 MAIN STREET
ALTAVISTA VA
24517
US

V. Phone/Fax

Practice location:
  • Phone: 434-369-4716
  • Fax: 434-369-4306
Mailing address:
  • Phone: 434-369-4716
  • Fax: 434-369-4306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number126
License Number StateVA

VIII. Authorized Official

Name: MR. JASON A BRADNER
Title or Position: PRESIDENT
Credential:
Phone: 434-369-4716