Basic Information
| Provider Information | |||||||||
| NPI: | 1801881651 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LITCHFIELD AMBULANCE ASSOCIATION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 195 ROUTE 80 | ||||||||
| Address2: | |||||||||
| City: | KILLINGWORTH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064191400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606633634 | ||||||||
| FaxNumber: | 8606633634 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 EAST ST | ||||||||
| Address2: | |||||||||
| City: | LITCHFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067593601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605679132 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | PUDLINSKI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8605670127 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 004235637 | 05 | CT | MEDICAID | 710C074B2CT01 | 01 | BLUE CROSS/BLUE SHIELD | OTHER |