Provider Demographics
NPI:1215120019
Name:LACEYVILLE AMBULANCE ASSOCIATION
Entity type:Organization
Organization Name:LACEYVILLE AMBULANCE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAPTAIN
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:SHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-869-2778
Mailing Address - Street 1:PO BOX 274
Mailing Address - Street 2:
Mailing Address - City:LACEYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18623-0274
Mailing Address - Country:US
Mailing Address - Phone:570-282-5652
Mailing Address - Fax:570-282-5653
Practice Address - Street 1:12 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LACEYVILLE
Practice Address - State:PA
Practice Address - Zip Code:18623
Practice Address - Country:US
Practice Address - Phone:570-282-5652
Practice Address - Fax:570-282-5653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X
PA051783416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012067070001Medicaid
PA0012067070001Medicaid