=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407375827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF GRANT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2017
-----------------------------------------------------
Last Update Date | 04/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 VIRGINIA AVE
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26847-1713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 681-592-0246
-----------------------------------------------------
Fax | 681-892-0248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 836 4TH AVE
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25701-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-521-1576
-----------------------------------------------------
Fax | 304-521-1576
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EMS DIRECTOR
-----------------------------------------------------
Name | JEREMY HOTTINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 681-892-0246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 61206
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------