Healthcare Provider Details

I. General information

NPI: 1437449220
Provider Name (Legal Business Name): LEGACY AMBULANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5453 GOVERNOR G C PEERY HWY
RAVEN VA
24639-9533
US

IV. Provider business mailing address

PO BOX 580
DORAN VA
24612-0580
US

V. Phone/Fax

Practice location:
  • Phone: 276-963-5323
  • Fax: 276-964-2972
Mailing address:
  • Phone: 276-963-5323
  • Fax: 276-964-2972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State

VIII. Authorized Official

Name: JERRY L DUNFORD
Title or Position: OWNER
Credential: EMT-INTERMEDIATE
Phone: 276-971-4407