Provider Demographics
NPI:1306326129
Name:LYON MOUNTAIN AMBULANCE SERVICES, INC
Entity type:Organization
Organization Name:LYON MOUNTAIN AMBULANCE SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-768-2192
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:LYON MOUNTAIN
Mailing Address - State:NY
Mailing Address - Zip Code:12952-0208
Mailing Address - Country:US
Mailing Address - Phone:518-735-4334
Mailing Address - Fax:
Practice Address - Street 1:9 FIREHOUSE RD
Practice Address - Street 2:
Practice Address - City:LYON MOUNTAIN
Practice Address - State:NY
Practice Address - Zip Code:12952
Practice Address - Country:US
Practice Address - Phone:518-735-4334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0917341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0917OtherNYS DEPARTMENT OF HEALTH