=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629377973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DADE COUNTY, GEORGIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2011
-----------------------------------------------------
Last Update Date | 03/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 CASE AVE
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30752-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-657-4625
-----------------------------------------------------
Fax | 706-657-5116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 613
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30752-0613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-657-4625
-----------------------------------------------------
Fax | 706-657-5116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. ALEX CASE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-657-4625
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 041-01
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------