=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639206899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIMS VOLUNTEER FIRE DEPARTMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 10/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12728 FM 729
-----------------------------------------------------
City | AVINGER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75630-8470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-755-4112
-----------------------------------------------------
Fax | 903-755-3219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12728 FM 729
-----------------------------------------------------
City | AVINGER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75630-8470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-755-4112
-----------------------------------------------------
Fax | 903-755-3219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY/TREASURER
-----------------------------------------------------
Name | MS. JUNE ROSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-755-4112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 300161
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------