Provider Demographics
NPI:1093700742
Name:SOUTHSIDE RESCUE SQUAD INC
Entity Type:Organization
Organization Name:SOUTHSIDE RESCUE SQUAD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:FLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-447-5038
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0660
Mailing Address - Country:US
Mailing Address - Phone:434-447-5038
Mailing Address - Fax:
Practice Address - Street 1:810 W ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1808
Practice Address - Country:US
Practice Address - Phone:434-447-5038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4906637Medicaid
VA351129OtherANTHEM