=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215215496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METROPOLITAN COMMUNITY DEVELOPMENT CORPORATION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2011
-----------------------------------------------------
Last Update Date | 07/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 DONNALLY ST
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25301-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-342-4775
-----------------------------------------------------
Fax | 304-342-4799
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 DONNALLY ST
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25301-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-342-4775
-----------------------------------------------------
Fax | 304-342-4799
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | PASTOR DARIN G FREEMAN SR.
-----------------------------------------------------
Credential | PASTOR
-----------------------------------------------------
Telephone | 304-342-4775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 1916971
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------