Provider Demographics
NPI:1295959799
Name:INDEPENDENT FIRE COMPANY NO. 1 OF CHARLES TOWN WEST VIRGINIA
Entity type:Organization
Organization Name:INDEPENDENT FIRE COMPANY NO. 1 OF CHARLES TOWN WEST VIRGINIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-521-1576
Mailing Address - Street 1:836 4TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-1407
Mailing Address - Country:US
Mailing Address - Phone:304-521-1576
Mailing Address - Fax:304-521-1768
Practice Address - Street 1:200 W. SECOND AVENUE
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1071
Practice Address - Country:US
Practice Address - Phone:304-725-2514
Practice Address - Fax:304-728-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV341600000X
WVWVEMS341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0145327000Medicaid
WV000236376OtherBCBS
WV000236376OtherBLUE CROSS WV
MD413426500Medicaid
WV000236376OtherBCBS