=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912683319
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORAM FIRE DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2023
-----------------------------------------------------
Last Update Date | 06/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 MIDDLE COUNTRY RD
-----------------------------------------------------
City | CORAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11727-4401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-732-5891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 MIDDLE COUNTRY RD
-----------------------------------------------------
City | CORAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11727-4401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DISTRICT MANAGER
-----------------------------------------------------
Name | VANDORN JOHNSON IV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-732-5891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------