Provider Demographics
NPI:1720204811
Name:JACKSON FIRST ALERT
Entity Type:Organization
Organization Name:JACKSON FIRST ALERT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WEATHERSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-471-2482
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29831-0332
Mailing Address - Country:US
Mailing Address - Phone:803-471-2637
Mailing Address - Fax:
Practice Address - Street 1:508 ATOMIC STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29831
Practice Address - Country:US
Practice Address - Phone:803-471-2637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCABO221Medicaid