=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619052099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY EMS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 12/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1550 HIGHWAY 31 NW
-----------------------------------------------------
City | HARTSELLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35640-4430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-773-2662
-----------------------------------------------------
Fax | 256-773-2662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 458
-----------------------------------------------------
City | MOULTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35650-0458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-773-2662
-----------------------------------------------------
Fax | 256-292-3514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TERRY GARWOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 256-637-0500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 886
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------