=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588196208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAVER LAKE FIRE DEPT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2017
-----------------------------------------------------
Last Update Date | 03/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8944 GRIMES DR
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72756-7879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-925-2082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8944 GRIMES DR
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72756-7879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FIRE CHIEF
-----------------------------------------------------
Name | JOHN WHISENANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-925-2082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------