Healthcare Provider Details

I. General information

NPI: 1093743775
Provider Name (Legal Business Name): LIBERTY COUNTY AMBULANCE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12503 NW VIRGINIA G WEAVER ST
BRISTOL FL
32321-0399
US

IV. Provider business mailing address

12503 NW VIRGINIA G WEAVER ST
BRISTOL FL
32321-0399
US

V. Phone/Fax

Practice location:
  • Phone: 850-643-5866
  • Fax: 850-643-2866
Mailing address:
  • Phone: 850-643-5866
  • Fax: 850-643-2866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number002611
License Number StateFL

VIII. Authorized Official

Name: MRS. KATHERINE H PIPPIN
Title or Position: DIRECTOR
Credential: PARAMEDIC
Phone: 850-643-5866