Healthcare Provider Details

I. General information

NPI: 1215120019
Provider Name (Legal Business Name): LACEYVILLE AMBULANCE ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EAST MAIN STREET
LACEYVILLE PA
18623
US

IV. Provider business mailing address

PO BOX 274
LACEYVILLE PA
18623-0274
US

V. Phone/Fax

Practice location:
  • Phone: 570-282-5652
  • Fax: 570-282-5653
Mailing address:
  • Phone: 570-282-5652
  • Fax: 570-282-5653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number05178
License Number StatePA

VIII. Authorized Official

Name: MR. ERIC RYAN SHAFER
Title or Position: CAPTAIN
Credential:
Phone: 570-869-2778