Healthcare Provider Details

I. General information

NPI: 1487608055
Provider Name (Legal Business Name): LIFESTAR AMBULANCE SERVICE,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 N ELM ST
CENTRALIA IL
62801-2326
US

IV. Provider business mailing address

940 N ELM ST PO BOX 1838
CENTRALIA IL
62801-2326
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-2474
  • Fax: 618-532-7795
Mailing address:
  • Phone: 618-532-2474
  • Fax: 618-532-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number5225
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: ROGER D. CAMPBELL
Title or Position: PRESIDENT
Credential:
Phone: 618-532-2474