Healthcare Provider Details

I. General information

NPI: 1558471664
Provider Name (Legal Business Name): JEFFERSONVILLE VOLUNTEER RESCUE SQUAD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 STEELES LANE
TAZEWELL VA
24651-9625
US

IV. Provider business mailing address

PO BOX 999
OCEANA WV
24870-0999
US

V. Phone/Fax

Practice location:
  • Phone: 276-988-9062
  • Fax: 276-988-9062
Mailing address:
  • Phone: 800-635-7577
  • Fax: 304-253-1965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number892
License Number StateVA

VIII. Authorized Official

Name: MR. KEITH A WAYCASTER
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 304-253-1059