Basic Information
| Provider Information | |||||||||
| NPI: | 1306838966 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINCHESTER-WAYNE TOWNSHIP LIFE SQUAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
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| Practice Location | |||||||||
| Address1: | 35 WASHINGTON ST | ||||||||
| Address2: | BOX 215 | ||||||||
| City: | WINCHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376950447 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 09/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHANEY | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 9376950447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 000000010000 | 01 | OH | ANTHEM | OTHER | 0457376 | 05 | OH | MEDICAID |