Healthcare Provider Details

I. General information

NPI: 1497839716
Provider Name (Legal Business Name): BEACON OF LIFE AMBULANCE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16559 RIVERSIDE DR
ST. PAUL VA
24283
US

IV. Provider business mailing address

109 S. MAIN ST
GALAX VA
24333
US

V. Phone/Fax

Practice location:
  • Phone: 276-237-7167
  • Fax: 276-236-4725
Mailing address:
  • Phone: 276-237-7167
  • Fax: 276-236-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: MS. OUIDA ANN JORDAN
Title or Position: CEO
Credential:
Phone: 276-237-1767