Healthcare Provider Details

I. General information

NPI: 1891013520
Provider Name (Legal Business Name): WISE RESCUE SQUAD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 06/18/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 RAILROAD AVE NE
WISE VA
24293-7802
US

IV. Provider business mailing address

PO BOX 9150
PADUCAH KY
42002-9150
US

V. Phone/Fax

Practice location:
  • Phone: 276-328-3063
  • Fax:
Mailing address:
  • Phone: 270-744-8413
  • Fax: 270-744-8642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number0004
License Number StateVA

VIII. Authorized Official

Name: MR. TIMOTHY DOTSON
Title or Position: CAPTAIN
Credential:
Phone: 276-328-3037