=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154742856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOCIETY HILL RESCUE SQUAD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2013
-----------------------------------------------------
Last Update Date | 12/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 SOUTH MAIN STREET
-----------------------------------------------------
City | SOCIETY HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-378-4660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 291
-----------------------------------------------------
City | SOCIETY HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29593-0291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EMS DIRECTOR
-----------------------------------------------------
Name | TIMOTHY JORDAN MARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-858-0634
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 066
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------