=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194929240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST CARTER COUNTY VOLUNTEER AMBULANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2007
-----------------------------------------------------
Last Update Date | 03/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | RT. 2 BOX 2004 SOUTH SIDE HWY. A AT WEST CITY LIMITS
-----------------------------------------------------
City | ELLSINORE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63937-0160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-322-8303
-----------------------------------------------------
Fax | 573-322-8303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 160 RT.2 BOX 2004
-----------------------------------------------------
City | ELLSINORE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63937-0160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-322-8303
-----------------------------------------------------
Fax | 573-322-8303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOOKKEEPER CREW CHIEF
-----------------------------------------------------
Name | MS. ERMA E DUCKETT
-----------------------------------------------------
Credential | PARAMEDIC
-----------------------------------------------------
Telephone | 573-322-8303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 4595
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------