=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003237249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURE LIFE AMBULANCE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2013
-----------------------------------------------------
Last Update Date | 12/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 TOMLINSON RD SUITE 103
-----------------------------------------------------
City | HUNTINGDON VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19006-4218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-789-8651
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 TOMLINSON RD SUITE 103
-----------------------------------------------------
City | HUNTINGDON VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19006-4218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RUVIM KOLESNIKOVICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-789-8651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------