Healthcare Provider Details

I. General information

NPI: 1811169865
Provider Name (Legal Business Name): ELITE AMBULANCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 VENICE BLVD
LOS ANGELES CA
90006-5222
US

IV. Provider business mailing address

2065 VENICE BLVD
LOS ANGELES CA
90006-5222
US

V. Phone/Fax

Practice location:
  • Phone: 323-874-4100
  • Fax: 323-766-9500
Mailing address:
  • Phone: 323-874-4100
  • Fax: 323-766-9500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: BRIDGETTE POVOLOTSKY
Title or Position: PRESIDENT
Credential:
Phone: 323-874-4100