=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770805582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | F.O.R.C.E.S. MEDICAL RESERVE CORPS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2010
-----------------------------------------------------
Last Update Date | 02/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2196 FM 1540
-----------------------------------------------------
City | SANDIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78383-2267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-547-1640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9
-----------------------------------------------------
City | SANDIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78383-0009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-547-1640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARAMEDIC/EMS DIRECTOR
-----------------------------------------------------
Name | MR. MATTHEW A CLARK
-----------------------------------------------------
Credential | LP
-----------------------------------------------------
Telephone | 361-547-1640
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 1000394
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------