Provider Demographics
NPI:1619969722
Name:TERRA ALTA COMMUNITY AMBULANCE
Entity Type:Organization
Organization Name:TERRA ALTA COMMUNITY AMBULANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:METHENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-789-6006
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-0129
Mailing Address - Country:US
Mailing Address - Phone:304-473-8988
Mailing Address - Fax:304-472-9849
Practice Address - Street 1:1124 E STATE AVE
Practice Address - Street 2:
Practice Address - City:TERRA ALTA
Practice Address - State:WV
Practice Address - Zip Code:26764-1465
Practice Address - Country:US
Practice Address - Phone:304-789-6566
Practice Address - Fax:304-789-6566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0145535000Medicaid
MD409853600Medicaid
WV0145535000Medicaid
WV9356721Medicare PIN