Provider Demographics
NPI:1386947901
Name:LIFEGUARD AMBULANCE SERVICE OF ALABAMA LLC
Entity type:Organization
Organization Name:LIFEGUARD AMBULANCE SERVICE OF ALABAMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-949-1719
Mailing Address - Street 1:PO BOX 190007
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35219-0007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 WALTER DAVIS DR
Practice Address - Street 2:SUITE C
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-2847
Practice Address - Country:US
Practice Address - Phone:205-380-2065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL831341600000X
AL971341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL128069Medicaid
AL1528067881OtherTRICARE-SOUTH
AL51121572OtherBCBS-AL
MS05373267Medicaid
FL108334Medicaid
AL136373Medicaid
AL51550455OtherBCBS-AL
MS05373267Medicaid
AL102G590250Medicare PIN