Provider Demographics
NPI:1710950704
Name:CANNON COUNTY AMBULANCE SERVICE
Entity Type:Organization
Organization Name:CANNON COUNTY AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-653-2655
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:270-744-8642
Practice Address - Street 1:104 ALEXANDER DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:TN
Practice Address - Zip Code:37190-5275
Practice Address - Country:US
Practice Address - Phone:615-563-5959
Practice Address - Fax:615-563-6878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2007454OtherTENN CARE NON EMERGENCY
TN4110424OtherTENN CARE EMERGENCY
TN4110424OtherBLUE CROSS BLUE SHIELD
TN3525445Medicaid
TN4110424OtherTENN CARE EMERGENCY