Provider Demographics
NPI:1063495240
Name:MECKLENBURG COUNTY LIFE SAVING & RESCUE SQUAD INC
Entity Type:Organization
Organization Name:MECKLENBURG COUNTY LIFE SAVING & RESCUE SQUAD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:OSBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-374-2466
Mailing Address - Street 1:PO BOX 1539
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23927-1539
Mailing Address - Country:US
Mailing Address - Phone:434-374-2466
Mailing Address - Fax:434-374-3332
Practice Address - Street 1:25 BURLINGTON DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23927-3235
Practice Address - Country:US
Practice Address - Phone:434-374-2466
Practice Address - Fax:434-374-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA168146L00000X, 3416L0300X, 146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3416L0300XTransportation ServicesAmbulanceLand TransportGroup - Multi-Specialty
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Multi-Specialty
Not Answered146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010190398Medicaid
VA010190398Medicaid