Provider Demographics
NPI:1205828944
Name:SOUTH MOUNTAIN VOLUNTEER FIRE COMPANY
Entity Type:Organization
Organization Name:SOUTH MOUNTAIN VOLUNTEER FIRE COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS SUPERVIOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:J
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-749-5733
Mailing Address - Street 1:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:SOUTH MOUNTAIN
Mailing Address - State:PA
Mailing Address - Zip Code:17261-0092
Mailing Address - Country:US
Mailing Address - Phone:717-749-5733
Mailing Address - Fax:717-749-5219
Practice Address - Street 1:11207 LOOP RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:PA
Practice Address - Zip Code:17222-9284
Practice Address - Country:US
Practice Address - Phone:717-749-5733
Practice Address - Fax:717-749-5219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018234600001Medicaid
MD411464700Medicaid
WV3810002579Medicaid
MD411464700Medicaid
WV3810002579Medicaid