Healthcare Provider Details

I. General information

NPI: 1609958792
Provider Name (Legal Business Name): 549 CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 MAIN STREET
EDWARDSVILLE PA
18704
US

IV. Provider business mailing address

645 MAIN STREET
EDWARDSVILLE PA
18704
US

V. Phone/Fax

Practice location:
  • Phone: 570-288-5770
  • Fax: 570-288-0112
Mailing address:
  • Phone: 570-288-5770
  • Fax: 570-288-0112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number03367
License Number StatePA

VIII. Authorized Official

Name: MR. MICHAEL KOWALSKI
Title or Position: PRESIDENT
Credential:
Phone: 570-288-5770