Healthcare Provider Details

I. General information

NPI: 1902127731
Provider Name (Legal Business Name): PEACH STATE AMBULANCE OF PR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR NUM 2 KM 97.7 BO COCOS
QUEBRADILLAS PR
00678-9998
US

IV. Provider business mailing address

58 CALLE SOCORRO PMB 22
QUEBRADILLAS PR
00678-1854
US

V. Phone/Fax

Practice location:
  • Phone: 787-213-7522
  • Fax: 787-551-7104
Mailing address:
  • Phone: 787-213-7522
  • Fax: 787-895-8282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License NumberTCAMB 646
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MRS. YASMIN DE LACRUZ RUIZ
Title or Position: PRESIDENT
Credential:
Phone: 787-213-7522