=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689713729
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST VOLUNTARY AMBULANCE ASSOCIATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 02/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 MEADOW DR BOX 461
-----------------------------------------------------
City | WEST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76691-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-826-3779
-----------------------------------------------------
Fax | 254-826-3149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 MEADOW DR P.O. BOX 461
-----------------------------------------------------
City | WEST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76691-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-826-3779
-----------------------------------------------------
Fax | 254-826-3149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MR. TOM EDWIN MAREK
-----------------------------------------------------
Credential | PARAMEDIC
-----------------------------------------------------
Telephone | 254-826-3779
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 300039
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------