=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386607539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAMSBURG AMBULANCE CLUB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 418 W SECOND ST
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-695-1421
-----------------------------------------------------
Fax | 814-695-8280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 SCOTCH VALLEY ROAD PO BOX 461
-----------------------------------------------------
City | HOLLIDAYSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16648-0461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-695-1421
-----------------------------------------------------
Fax | 814-695-8280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER BOARD OF DIRECTORS
-----------------------------------------------------
Name | JUDITH E MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-695-1421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 03149
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------