=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336533033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATOAKA VOLUNTEER FIRE DEPARTMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2015
-----------------------------------------------------
Last Update Date | 03/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 FIRST AVENUE
-----------------------------------------------------
City | MATOAKA
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-467-8385
-----------------------------------------------------
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 | EMS CHIEF
-----------------------------------------------------
Name | JOHN SOMMERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-467-8385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------