Provider Demographics
NPI:1043091176
Name:BLACK JACK FIRE PROTECTION DIST
Entity type:Organization
Organization Name:BLACK JACK FIRE PROTECTION DIST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPUTY CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:M
Authorized Official - Last Name:KERCKHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:314-741-9905
Mailing Address - Street 1:5675 N HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2603
Mailing Address - Country:US
Mailing Address - Phone:314-741-9905
Mailing Address - Fax:
Practice Address - Street 1:5675 N HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-2603
Practice Address - Country:US
Practice Address - Phone:314-741-9905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-13
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport