Healthcare Provider Details

I. General information

NPI: 1609866094
Provider Name (Legal Business Name): RAVENA RESCUE SQUAD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BRUNO BLVD
RAVENA NY
12143-1625
US

IV. Provider business mailing address

107 WASHINGTON AVE
ALBANY NY
12210-2231
US

V. Phone/Fax

Practice location:
  • Phone: 518-756-2096
  • Fax: 518-756-6015
Mailing address:
  • Phone: 888-603-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number0468
License Number StateNY

VIII. Authorized Official

Name: MR. BRIAN DUNICAN
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 888-603-2455