Provider Demographics
NPI:1063566305
Name:MOUNTAINEER AMBULANCE SERVICE, INC.
Entity type:Organization
Organization Name:MOUNTAINEER AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD OF DIRECTORS SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDESTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-892-3202
Mailing Address - Street 1:PO BOX 999
Mailing Address - Street 2:
Mailing Address - City:OCEANA
Mailing Address - State:WV
Mailing Address - Zip Code:24870-0999
Mailing Address - Country:US
Mailing Address - Phone:304-253-1059
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 248
Practice Address - Street 2:
Practice Address - City:TUNNELTON
Practice Address - State:WV
Practice Address - Zip Code:26444-9745
Practice Address - Country:US
Practice Address - Phone:304-253-1059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVNO NUMBER3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0145398000Medicaid
WV9121982Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER