Healthcare Provider Details

I. General information

NPI: 1023189925
Provider Name (Legal Business Name): MAD RIVER VALLEY AMBULANCE SERVICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4177 MAIN ST
WAITSFIELD VT
05673-6095
US

IV. Provider business mailing address

PO BOX 305
WAITSFIELD VT
05673-0305
US

V. Phone/Fax

Practice location:
  • Phone: 802-496-8888
  • Fax: 802-329-2142
Mailing address:
  • Phone: 802-496-8888
  • Fax: 802-329-2142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License NumberVT6442
License Number StateVT

VIII. Authorized Official

Name: ROBIN M KINSELLA
Title or Position: CLAIMS ADMINISTRATOR
Credential:
Phone: 802-496-8888