Provider Demographics
NPI:1790846665
Name:WAYNE COUNTY AMBULANCE SERVICE
Entity Type:Organization
Organization Name:WAYNE COUNTY AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-427-5999
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31598-0270
Mailing Address - Country:US
Mailing Address - Phone:912-427-5999
Mailing Address - Fax:912-427-5906
Practice Address - Street 1:477 W BAY ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-1223
Practice Address - Country:US
Practice Address - Phone:912-427-5999
Practice Address - Fax:912-427-5906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA151-013416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA590008778OtherRAILROAD MEDICARE
GA000348444AMedicaid
GA85029659AAMedicare ID - Type Unspecified