Provider Demographics
NPI:1942406475
Name:COUNTY OF LAFAYETTE OFFICE CLERK BOARD COUNTY COMMISSIONERS
Entity Type:Organization
Organization Name:COUNTY OF LAFAYETTE OFFICE CLERK BOARD COUNTY COMMISSIONERS
Other - Org Name:LAFAYETTE COUNTY RESCUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:PMD,BSBA,RN,FP-C
Authorized Official - Phone:386-294-1633
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:MAYO
Mailing Address - State:FL
Mailing Address - Zip Code:32066-0088
Mailing Address - Country:US
Mailing Address - Phone:386-294-1633
Mailing Address - Fax:386-294-4242
Practice Address - Street 1:136 S.E. INDUSTRIAL AVENUE
Practice Address - Street 2:
Practice Address - City:MAYO
Practice Address - State:FL
Practice Address - Zip Code:32066
Practice Address - Country:US
Practice Address - Phone:386-294-1633
Practice Address - Fax:386-294-4242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2010-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2655341600000X
FL2915341600000X
FL2978341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA0600OtherBLUE CROSS / BLUE SHIELD
FL400118400Medicaid
FLSG1611OtherMETCARE HEALTH PLANS, INC
FL220145OtherAVMED HEALTH PLAN
FL400118400Medicaid