Provider Demographics
NPI:1306889431
Name:JEB STUART RESCUE SQUAD INCORPORATED
Entity type:Organization
Organization Name:JEB STUART RESCUE SQUAD INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-229-6272
Mailing Address - Street 1:PO BOX 290184
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06129-0184
Mailing Address - Country:US
Mailing Address - Phone:860-257-7080
Mailing Address - Fax:860-563-3403
Practice Address - Street 1:1258 AMERICAN LEGION RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171
Practice Address - Country:US
Practice Address - Phone:276-694-6171
Practice Address - Fax:276-694-5366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA158341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010209196Medicaid
VA010209196Medicaid