Healthcare Provider Details

I. General information

NPI: 1164410601
Provider Name (Legal Business Name): GARDNER LAKE VOLUNTEER FIRE COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 OLD COLCHESTER RD
SALEM CT
06420-3748
US

IV. Provider business mailing address

PO BOX 290184
WETHERSFIELD CT
06129-0184
US

V. Phone/Fax

Practice location:
  • Phone: 860-859-1743
  • Fax: 860-892-5392
Mailing address:
  • Phone: 800-452-8191
  • Fax: 860-563-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License NumberC121B1
License Number StateCT

VIII. Authorized Official

Name: MARY GENTILE
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 800-452-8191