MEDICARE: MECKLENBURG COUNTY LIFE SAVING & RESCUE SQUAD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	146L00000X	Paramedic	168	VA
2	3416L0300X	Land Ambulance	168	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063495240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MECKLENBURG COUNTY LIFE SAVING & RESCUE SQUAD INC

Provider Business Mailing Address
First Line	:	PO BOX 1539
Second Line	:
City	:	CLARKSVILLE
State	:	VA
Zip	:	23927-1539
Country	:	US
Telephone Number	:	434-374-2466
Fax Number	:	434-374-3332

Provider Business Practice Location Address
First Line	:	25 BURLINGTON DR
Second Line	:
City	:	CLARKSVILLE
State	:	VA
Zip	:	23927-3235
Country	:	US
Telephone Number	:	434-374-2466
Fax Number	:	434-374-3332

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	MR. DEBORAH OSBORN
Credential	:
Telephone Number	:	434-374-2466

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	02/09/2016

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