Provider Demographics
NPI:1013028158
Name:BLUEFIELD VIRGINIA RESCUE SQUAD, INC.
Entity Type:Organization
Organization Name:BLUEFIELD VIRGINIA RESCUE SQUAD, INC.
Other - Org Name:BLUEFIELD VA RESCUE SQUAD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR CAPTAIN
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-326-3763
Mailing Address - Street 1:PO BOX 999
Mailing Address - Street 2:
Mailing Address - City:OCEANA
Mailing Address - State:WV
Mailing Address - Zip Code:24870-0999
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:217 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-1919
Practice Address - Country:US
Practice Address - Phone:276-326-3763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANO NUMBER ON LICENSE3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9000013000Medicaid