Provider Demographics
NPI:1699752998
Name:LIFESTAR LLC
Entity type:Organization
Organization Name:LIFESTAR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF BILLING SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:VASSALLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:602-437-6620
Mailing Address - Street 1:PO BOX 63068
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-3068
Mailing Address - Country:US
Mailing Address - Phone:602-437-1431
Mailing Address - Fax:602-437-8436
Practice Address - Street 1:1014 S WESTERLY
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541
Practice Address - Country:US
Practice Address - Phone:928-474-2831
Practice Address - Fax:928-474-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ590015162OtherRR MEDICARE
AZAZ0152310OtherBCBS
AZ620949Medicaid
X65940Medicare UPIN
AZ620949Medicaid