Healthcare Provider Details

I. General information

NPI: 1306889431
Provider Name (Legal Business Name): JEB STUART RESCUE SQUAD INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 AMERICAN LEGION RD
STUART VA
24171
US

IV. Provider business mailing address

PO BOX 290184
WETHERSFIELD CT
06129-0184
US

V. Phone/Fax

Practice location:
  • Phone: 276-694-6171
  • Fax: 276-694-5366
Mailing address:
  • Phone: 860-257-7080
  • Fax: 860-563-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number158
License Number StateVA

VIII. Authorized Official

Name: JIMMY WILLARD
Title or Position: PRESIDENT
Credential:
Phone: 276-229-6272