Provider Demographics
NPI:1922023605
Name:DUSHORE FIRE CO 1
Entity Type:Organization
Organization Name:DUSHORE FIRE CO 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLERICAL BILLING AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-268-2417
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-0111
Mailing Address - Country:US
Mailing Address - Phone:570-268-2417
Mailing Address - Fax:570-265-4797
Practice Address - Street 1:JULIA ST
Practice Address - Street 2:
Practice Address - City:DUSHORE
Practice Address - State:PA
Practice Address - Zip Code:18614
Practice Address - Country:US
Practice Address - Phone:570-928-8508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05128341600000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009433010003Medicaid
284561Medicare ID - Type Unspecified