Provider Demographics
NPI:1215033865
Name:CITY OF SOUTHAVEN
Entity Type:Organization
Organization Name:CITY OF SOUTHAVEN
Other - Org Name:SOUTHAVEN FIRE DEPARTMENT AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCALLIONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-393-7466
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:8710 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2410
Practice Address - Country:US
Practice Address - Phone:662-393-7466
Practice Address - Fax:662-393-7294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1283416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07774861Medicaid
MS223862186OtherBCBS
MS07774861Medicaid
W55041Medicare UPIN