=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558308932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHALLOTTE VOLUNTEER RESCUE SQUAD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 VILLAGE RD
-----------------------------------------------------
City | SHALLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28470-4440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-754-8292
-----------------------------------------------------
Fax | 910-755-8292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 167
-----------------------------------------------------
City | SHALLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28459-0167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-754-8292
-----------------------------------------------------
Fax | 910-755-8292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF
-----------------------------------------------------
Name | MR. HUGH MARK GORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-754-8292
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------