Healthcare Provider Details

I. General information

NPI: 1285622647
Provider Name (Legal Business Name): BEACON VOLUNTEER AMBULANCE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AQUILLA DR
BEACON NY
12508-2054
US

IV. Provider business mailing address

PO BOX 290184
WETHERSFIELD CT
06129-0184
US

V. Phone/Fax

Practice location:
  • Phone: 845-831-4540
  • Fax: 845-831-0191
Mailing address:
  • Phone: 800-452-8191
  • Fax: 860-721-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number1314
License Number StateNY

VIII. Authorized Official

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