1104899384 NPI number — STORM ENGINE CO AMBULANCE CORPS

Table of content: (NPI 1104899384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104899384 NPI number — STORM ENGINE CO AMBULANCE CORPS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STORM ENGINE CO AMBULANCE CORPS
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:
1104899384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
269 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROMWELL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06416-2302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-638-1800
Provider Business Mailing Address Fax Number:
860-638-1802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 OLIVIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DERBY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06418-1712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-735-1347
Provider Business Practice Location Address Fax Number:
203-735-4873
Provider Enumeration Date:
02/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LENHART
Authorized Official First Name:
TOM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-735-1347

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)

  • Identifier: 004225290 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 710C037A2CT01 . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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