1497839716 NPI number — BEACON OF LIFE AMBULANCE SERVICE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497839716 NPI number — BEACON OF LIFE AMBULANCE SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON OF LIFE AMBULANCE SERVICE
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:
1497839716
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 S. MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-237-7167
Provider Business Mailing Address Fax Number:
276-236-4725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16559 RIVERSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. PAUL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-237-7167
Provider Business Practice Location Address Fax Number:
276-236-4725
Provider Enumeration Date:
10/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JORDAN
Authorized Official First Name:
OUIDA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
276-237-1767

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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