=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245409358
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIZEMORE VOLUNTEER FIRE DEPARTMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2008
-----------------------------------------------------
Last Update Date | 09/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13175 CLAY HIGHWAY
-----------------------------------------------------
City | LIZEMORE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-587-6056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 836 4TH AVE
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25701-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF
-----------------------------------------------------
Name | MITZIE FOSTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-587-6056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | WV EMS
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------