=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972718492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROANE COUNTY COMMITTEE ON AGING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 811 MADISON AVE
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25276-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-927-1997
-----------------------------------------------------
Fax | 304-927-2273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 811 MADISON AVE
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25276-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-927-1997
-----------------------------------------------------
Fax | 304-927-2273
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | CHUCK RICKS
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 304-927-1997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 001
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------