Basic Information
| Provider Information | |||||||||
| NPI: | 1053614503 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFECARE AMBULETTE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1224 BRUNSWICK AVE | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116913920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467723668 | ||||||||
| FaxNumber: | 7183273010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1224 BRUNSWICK AVE | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116913920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467723668 | ||||||||
| FaxNumber: | 7183273010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2010 | ||||||||
| LastUpdateDate: | 12/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | LAHASKY | ||||||||
| AuthorizedOfficialFirstName: | MORDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6467723668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 343900000X | 30354 | NY | Y | Transportation Services | Non-emergency Medical Transport (VAN) |
ID Information
| ID | Type | State | Issuer | Description | 30534 | 01 | NY | NYS DOT | OTHER |