Healthcare Provider Details

I. General information

NPI: 1063501153
Provider Name (Legal Business Name): STAFFORD EMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4071 VENUS ST
GILBERT WV
25621-1098
US

IV. Provider business mailing address

PO BOX 1098
GILBERT WV
25621-1098
US

V. Phone/Fax

Practice location:
  • Phone: 304-664-2330
  • Fax:
Mailing address:
  • Phone: 304-664-2330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number045225
License Number StateWV

VIII. Authorized Official

Name: KENDELL A SIMPSON
Title or Position: OWNER
Credential:
Phone: 304-664-2330