MEDICARE: VANGUARD 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	3416L0300X	Land Ambulance

General Provider Information

NPI Number	:	1720607369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANGUARD AMBULANCE LLC

Provider Business Mailing Address
First Line	:	10712 PRUETT LN
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-4554
Country	:	US
Telephone Number	:	804-640-9429
Fax Number	:

Provider Business Practice Location Address
First Line	:	8417 ERLE RD BAY A
Second Line	:
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23116-1507
Country	:	US
Telephone Number	:	804-814-9150
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. KEVIN THOMAS PEPPERL
Credential	:
Telephone Number	:	804-640-9429

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	04/14/2020

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