Healthcare Provider Details

I. General information

NPI: 1063419620
Provider Name (Legal Business Name): LINCOLN COUNTY AMB DIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1392 SOUTH 3RD ST
TROY MO
63379
US

IV. Provider business mailing address

PO BOX 157
TROY MO
63379-0157
US

V. Phone/Fax

Practice location:
  • Phone: 636-528-8488
  • Fax: 636-528-6828
Mailing address:
  • Phone: 636-528-8488
  • Fax: 636-528-6828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number113000
License Number StateMO

VIII. Authorized Official

Name: MR. RAY ANTONACCI
Title or Position: CHIEF ADMINISTRATOR
Credential:
Phone: 636-295-2186