Provider Demographics
NPI:1881806909
Name:CITY OF PORT ORANGE
Entity type:Organization
Organization Name:CITY OF PORT ORANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:TROY
Authorized Official - Last Name:RAFFERTY
Authorized Official - Suffix:
Authorized Official - Credentials:NREMT-P
Authorized Official - Phone:386-756-5410
Mailing Address - Street 1:1000 CITY CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4144
Mailing Address - Country:US
Mailing Address - Phone:386-756-5410
Mailing Address - Fax:386-756-5405
Practice Address - Street 1:1000 CITY CENTER CIR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4144
Practice Address - Country:US
Practice Address - Phone:386-756-5410
Practice Address - Fax:386-756-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2725251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLX8069Medicare ID - Type UnspecifiedPROVIDER