Basic Information
| Provider Information | |||||||||
| NPI: | 1265933980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIME ROCK PARK, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LIME ROCK PARK AMBULANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 195 ROUTE 80 | ||||||||
| Address2: | |||||||||
| City: | KILLINGWORTH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064191400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604524502 | ||||||||
| FaxNumber: | 8606633795 | ||||||||
| Practice Location | |||||||||
| Address1: | 497 LIME ROCK RD | ||||||||
| Address2: | |||||||||
| City: | LAKEVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060392407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604355000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2018 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SAWICKI | ||||||||
| AuthorizedOfficialFirstName: | ZACH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF EMERGENCY SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8604355000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | C122B2 | CT | Y | Transportation Services | Ambulance | Land Transport |
No ID Information.