Healthcare Provider Details

I. General information

NPI: 1437149994
Provider Name (Legal Business Name): OLD LYME SOUTH END VOLUNTEER AMBULANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 CROSS LN
OLD LYME CT
06371-2115
US

IV. Provider business mailing address

PO BOX 290184
WETHERSFIELD CT
06129-0184
US

V. Phone/Fax

Practice location:
  • Phone: 860-434-0089
  • Fax: 860-434-8052
Mailing address:
  • Phone: 860-257-9201
  • Fax: 860-721-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License NumberC105B1
License Number StateCT

VIII. Authorized Official

Name: MS. MARY T GENTILE
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 860-257-9201