1184743015 NPI number — S TX LIFESTAR AMBULANCE SRVC

Table of content: (NPI 1184743015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184743015 NPI number — S TX LIFESTAR AMBULANCE SRVC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S TX LIFESTAR AMBULANCE SRVC
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:
LIFESTAR EMS
Provider Other Organization Name Type Code:
3
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:
1184743015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 808
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROMA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78584-0808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-847-1002
Provider Business Mailing Address Fax Number:
956-847-1317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4839 OLD ESCOBARES HWY 83
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROMA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-847-1002
Provider Business Practice Location Address Fax Number:
956-847-1317
Provider Enumeration Date:
03/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
DEYANIRA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
956-533-5485

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  214004 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 163777901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".