1023048261 NPI number — KILLINGWORTH AMBULANCE ASSOCIATION, INC

Table of content: (NPI 1023048261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023048261 NPI number — KILLINGWORTH AMBULANCE ASSOCIATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KILLINGWORTH AMBULANCE ASSOCIATION, 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:
1023048261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
195 ROUTE 80
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLINGWORTH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06419-1400
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:
325 ROUTE 81
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KILLINGWORTH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06419-9999
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:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
O'SULLIVAN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-663-2450

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  E5415 , 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: 699842 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 590014003 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004010492 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 710C070A2CT01 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: CT2195 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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