=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942328018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEWETT EMS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 11/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 W. MEXIA HWY
-----------------------------------------------------
City | JEWETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75846-0491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-626-4958
-----------------------------------------------------
Fax | 903-626-6788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 491
-----------------------------------------------------
City | JEWETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75846-0491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-626-4958
-----------------------------------------------------
Fax | 903-626-6788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. JOEL G. GRAY
-----------------------------------------------------
Credential | NREMTP
-----------------------------------------------------
Telephone | 903-626-4958
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 145005
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------