Provider Demographics
NPI:1720409246
Name:SANDY RIDGE RESCUE SQUAD
Entity Type:Organization
Organization Name:SANDY RIDGE RESCUE SQUAD
Other - Org Name:SANDY RIDGE VOLUNTEER RESCUE SQUAD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/CAPTAIN
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:SLEMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-395-3847
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:NORA
Mailing Address - State:VA
Mailing Address - Zip Code:24272-0550
Mailing Address - Country:US
Mailing Address - Phone:276-395-3847
Mailing Address - Fax:276-395-3847
Practice Address - Street 1:109 CARICO RDG
Practice Address - Street 2:
Practice Address - City:COEBURN
Practice Address - State:VA
Practice Address - Zip Code:24230-6418
Practice Address - Country:US
Practice Address - Phone:276-395-3847
Practice Address - Fax:276-395-3847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA618431700OtherFEDERAL BLACK LUNG PROGRAM
VA1720409246Medicaid
VA618431700OtherDEPARTMENT OF LABOR
VA1720409246Medicaid
VA618431700OtherFEDERAL BLACK LUNG PROGRAM