Healthcare Provider Details

I. General information

NPI: 1063715738
Provider Name (Legal Business Name): LIFE SHIELD EMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1158 FOREST PKWY SUITE A
LAKE CITY GA
30260-3464
US

IV. Provider business mailing address

1158 FOREST PKWY SUITE A
LAKE CITY GA
30260-3464
US

V. Phone/Fax

Practice location:
  • Phone: 678-814-4550
  • Fax: 770-783-6622
Mailing address:
  • Phone: 678-814-4550
  • Fax: 770-783-6622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code341600000X
TaxonomyAmbulance
License Number031-26
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number031-25
License Number StateGA

VIII. Authorized Official

Name: MR. STEVE THACH
Title or Position: CEO
Credential:
Phone: 678-814-4550