=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790186245
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOUVERNEUR VOLUNTEER RESCUE SQUAD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2014
-----------------------------------------------------
Last Update Date | 09/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1024 US HIGHWAY 11
-----------------------------------------------------
City | GOUVERNEUR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13642-3507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-287-1321
-----------------------------------------------------
Fax | 315-287-3854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 164
-----------------------------------------------------
City | GOUVERNEUR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13642-0164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-287-1321
-----------------------------------------------------
Fax | 315-287-3954
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. MARK A DEAVERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-287-1321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 43946
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 4417
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------