=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851593479
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COOPER COUNTY AMBULANCE DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2007
-----------------------------------------------------
Last Update Date | 09/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17651 B HIGHWAY
-----------------------------------------------------
City | BOONVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-882-4105
-----------------------------------------------------
Fax | 660-882-8108
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 414
-----------------------------------------------------
City | BOONVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-882-4105
-----------------------------------------------------
Fax | 660-882-8108
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | PAT OSWALD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 660-882-4105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 24836
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 053007
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------