Provider Demographics
NPI:1558471664
Name:JEFFERSONVILLE VOLUNTEER RESCUE SQUAD INC
Entity Type:Organization
Organization Name:JEFFERSONVILLE VOLUNTEER RESCUE SQUAD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAYCASTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-253-1059
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:800-635-7577
Mailing Address - Fax:304-253-1965
Practice Address - Street 1:407 STEELES LANE
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24651-9625
Practice Address - Country:US
Practice Address - Phone:276-988-9062
Practice Address - Fax:276-988-9062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA892341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00605846OtherRAILROAD MEDICARE
VA1558471664Medicaid
WV3810012977Medicaid
VA190002139Medicare UPIN
VAP00605846OtherRAILROAD MEDICARE