=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225415573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OAKWAY RESCUE SQUAD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2015
-----------------------------------------------------
Last Update Date | 03/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5480 WEST OAK HIGHWAY
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-972-7377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 62
-----------------------------------------------------
City | FAIR PLAY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29643-0062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-972-7377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SAMUEL JAMES MAST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-972-7377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 379
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------