1114973245 NPI number — DURHAM VOLUNTEER AMBULANCE CORPS INC

Table of content: (NPI 1114973245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114973245 NPI number — DURHAM VOLUNTEER AMBULANCE CORPS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DURHAM VOLUNTEER AMBULANCE CORPS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114973245
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06422-0207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-663-3634
Provider Business Mailing Address Fax Number:
860-663-3795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06422-2108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-663-3634
Provider Business Practice Location Address Fax Number:
860-663-3795
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIMLER
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OF SERVICE
Authorized Official Telephone Number:
860-349-9966

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  E5455 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CW0088 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 710C038B1CT01 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 506411 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004243789 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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