MEDICARE: LOW COUNTRY AMBULANCE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	341600000X	Ambulance	235	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	235	OTHER	SC	DHEC AMBUANCE SERVICE

General Provider Information

NPI Number	:	1326227505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOW COUNTRY AMBULANCE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 6708
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29502-6708
Country	:	US
Telephone Number	:	843-662-8887
Fax Number	:	843-662-9920

Provider Business Practice Location Address
First Line	:	4790 TRADE ST
Second Line	:	SUITE L
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29418-2833
Country	:	US
Telephone Number	:	843-225-1436
Fax Number	:	843-225-0295

Authorized Official
Title or Position	:	REGIONAL DIRECTOR
Name	:	MR. JOHN KEVIN FABIAN
Credential	:	PARAMEDIC
Telephone Number	:	843-534-3022

Provider Enumeration Date	:	10/24/2007
Last Update Date	:	10/24/2007

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