Basic Information
| Provider Information | |||||||||
| NPI: | 1912949652 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST LA AMBULANCE SVC LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 27 | ||||||||
| Address2: | |||||||||
| City: | WINNSBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184358351 | ||||||||
| FaxNumber: | 3184358319 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 TAYLOR AVE | ||||||||
| Address2: | |||||||||
| City: | WINNSBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184358351 | ||||||||
| FaxNumber: | 3184358319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELDRIDGE | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3184358351 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 9110044 | LA | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 1560782 | 05 | LA | MEDICAID |