1659428639 NPI number — BLOOMSBURG VOLUNTEER AMBULANCE ASSOCIATION, INC.

Table of content: (NPI 1659428639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659428639 NPI number — BLOOMSBURG VOLUNTEER AMBULANCE ASSOCIATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMSBURG VOLUNTEER 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:
1659428639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17815-0120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-387-5140
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 E. MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815-1870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-387-5140
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-387-5140

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X , with the licence number:  02173 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0009983640003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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