=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043647902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMEGA AMBULANCE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2013
-----------------------------------------------------
Last Update Date | 10/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 BUCK RD STE 4
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18966-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-262-0068
-----------------------------------------------------
Fax | 215-494-1970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 BUCK RD STE 4
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18966-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-262-0068
-----------------------------------------------------
Fax | 215-494-1970
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. VOLODIMYR MATKIVSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 267-262-0068
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 13019
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------