Provider Demographics
NPI:1699759639
Name:PROMEDIC AMBULANCE SERVICE
Entity type:Organization
Organization Name:PROMEDIC AMBULANCE SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VELAZQUEZ
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-764-4882
Mailing Address - Street 1:411 SOLDADO ALCIDES REYES ST.
Mailing Address - Street 2:SAN AGUSTIN
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00928
Mailing Address - Country:US
Mailing Address - Phone:787-764-4882
Mailing Address - Fax:787-754-7864
Practice Address - Street 1:411 SOLDADO ALCIDES REYES ST.
Practice Address - Street 2:SAN AGUSTIN
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00928
Practice Address - Country:US
Practice Address - Phone:787-764-4882
Practice Address - Fax:787-754-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0053463Medicare ID - Type UnspecifiedAMBULANCE