Provider Demographics
NPI:1619054913
Name:CLEVELAND COUNTY LIFE SAVING AND RESCUE SQUAD INC
Entity type:Organization
Organization Name:CLEVELAND COUNTY LIFE SAVING AND RESCUE SQUAD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAPTAIN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:704-739-2077
Mailing Address - Street 1:1324 SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-2628
Mailing Address - Country:US
Mailing Address - Phone:704-739-2077
Mailing Address - Fax:704-739-2995
Practice Address - Street 1:312 E PARKER ST
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3025
Practice Address - Country:US
Practice Address - Phone:704-739-2077
Practice Address - Fax:704-739-2995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406922Medicaid
NC073C2OtherBCBSNC
NC2783175Medicare PIN