=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538170956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLYTHEVILLE CITIZENS BAND RADIO CLUB INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 01/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 CHICKASAWBA ST
-----------------------------------------------------
City | BLYTHEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72315-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-740-2248
-----------------------------------------------------
Fax | 870-763-6794
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 CHICKASAWBA ST
-----------------------------------------------------
City | BLYTHEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72315-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-740-2248
-----------------------------------------------------
Fax | 870-763-6794
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF
-----------------------------------------------------
Name | MR. MIKE GODSEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-740-2248
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 368
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------