=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033173828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACKLICK VALLEY FOUNDATION AND AMBULANCE SERVICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2006
-----------------------------------------------------
Last Update Date | 12/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1077 1ST ST
-----------------------------------------------------
City | NANTY GLO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15943-1159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-749-7332
-----------------------------------------------------
Fax | 814-749-7188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1077 1ST ST
-----------------------------------------------------
City | NANTY GLO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15943-1159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-749-7332
-----------------------------------------------------
Fax | 814-749-7188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BEVERLY SHERWOOD-BURNS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-749-7332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 03150
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------