1821141821 NPI number — AMBUCARE, LLC

Table of content: (NPI 1821141821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821141821 NPI number — AMBUCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMBUCARE, LLC
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:
AMBUCARE, INC
Provider Other Organization Name Type Code:
4
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:
1821141821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7179
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60197-7179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-597-4911
Provider Business Mailing Address Fax Number:
866-687-2796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1196 HIGHTOWER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREMEN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30110-4382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-537-1946
Provider Business Practice Location Address Fax Number:
770-537-2744
Provider Enumeration Date:
01/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JEWELL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF REVENUE INTEGRATION OFFICER
Authorized Official Telephone Number:
844-597-4911

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  071-04 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000652308A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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