Provider Demographics
NPI:1306143342
Name:SAM'S AMBULETTE SERVICE, LLC
Entity type:Organization
Organization Name:SAM'S AMBULETTE SERVICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ISMAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TABALNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-249-8300
Mailing Address - Street 1:PO BOX 98724
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-0724
Mailing Address - Country:US
Mailing Address - Phone:253-249-8300
Mailing Address - Fax:206-429-3122
Practice Address - Street 1:25611 16TH AVE S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-8953
Practice Address - Country:US
Practice Address - Phone:253-249-8300
Practice Address - Fax:206-429-3122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA05087343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)