Basic Information
| Provider Information | |||||||||
| NPI: | 1295965606 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEVILLE AMBULETTE TRANSPORTATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27111 76TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182892100 | ||||||||
| FaxNumber: | 7182892323 | ||||||||
| Practice Location | |||||||||
| Address1: | 27111 76TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182892100 | ||||||||
| FaxNumber: | 7182892323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2009 | ||||||||
| LastUpdateDate: | 07/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | WERNER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7182892354 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARKER JEWISH INSTITUTE FOR HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 343900000X | Y | Transportation Services | Non-emergency Medical Transport (VAN) |
ID Information
| ID | Type | State | Issuer | Description | 02975313 | 05 | NY | MEDICAID |