=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023299633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTON VOLUNTEER RESCUE SQUAD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2007
-----------------------------------------------------
Last Update Date | 10/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 CRAIG STREET
-----------------------------------------------------
City | GASTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27832-0699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-535-2173
-----------------------------------------------------
Fax | 252-535-4226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 25863
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27114-5863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-946-1766
-----------------------------------------------------
Fax | 336-946-1768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL
-----------------------------------------------------
Name | CHRISTY SUMMERLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-535-2173
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 1392
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------