Provider Demographics
NPI:1215929401
Name:STAFFORD AMBULANCE ASSOCIATION INC.
Entity type:Organization
Organization Name:STAFFORD AMBULANCE ASSOCIATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBULANCE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-684-5364
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:WEST SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06093-0204
Mailing Address - Country:US
Mailing Address - Phone:860-668-3885
Mailing Address - Fax:860-668-3885
Practice Address - Street 1:27 WILLINGTON AVE
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-1620
Practice Address - Country:US
Practice Address - Phone:860-668-3885
Practice Address - Fax:860-668-3885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC134B1341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
105028000OtherDEPT OF LABOR
CT710C134A2CT01OtherANTHEM BLUE CROSS BS
CT004142890Medicaid
00414289000OtherBLUE CARE FAMILY
784671OtherCONNECTICARE
784671OtherCONNECTICARE
105028000OtherDEPT OF LABOR