Provider Demographics
NPI:1407850159
Name:LIBERTY AMBULANCE SERVICE INC
Entity type:Organization
Organization Name:LIBERTY AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ASSAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-721-0008
Mailing Address - Street 1:1626 ATLANTIC UNIVERSITY CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2227
Mailing Address - Country:US
Mailing Address - Phone:904-805-0293
Mailing Address - Fax:904-724-0226
Practice Address - Street 1:1626 ATLANTIC UNIVERSITY CIR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2227
Practice Address - Country:US
Practice Address - Phone:904-805-0293
Practice Address - Fax:904-724-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0024703416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL099501100Medicaid
FLA0554Medicare PIN