=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679809990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE AMBULANCE SERVICE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2009
-----------------------------------------------------
Last Update Date | 03/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BUSINESS CT SUITE A
-----------------------------------------------------
City | AIKEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29801-4096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-641-6434
-----------------------------------------------------
Fax | 803-641-6436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 BUSINESS CT SUITE A
-----------------------------------------------------
City | AIKEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29801-4096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-641-6434
-----------------------------------------------------
Fax | 803-641-6436
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | MR. DOUG MCDANIEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-641-6434
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 256
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------