Provider Demographics
NPI:1336445766
Name:LEAD MINES RESCUE SQUAD INC
Entity Type:Organization
Organization Name:LEAD MINES RESCUE SQUAD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-620-8916
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-4864
Practice Address - Street 1:1057 FORT CHISWELL RD
Practice Address - Street 2:
Practice Address - City:MAX MEADOWS
Practice Address - State:VA
Practice Address - Zip Code:24360-3004
Practice Address - Country:US
Practice Address - Phone:276-764-2101
Practice Address - Fax:276-764-2102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336445766Medicaid
P00994002Medicare PIN
VA190002206Medicare PIN