=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134453210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REAL AMBULANCE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2009
-----------------------------------------------------
Last Update Date | 09/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | EXT SAN AGUSTIN CALLE 10 B11
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-478-2050
-----------------------------------------------------
Fax | 787-764-7796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | EXT SAN AGUSTIN CALLE 10 B11
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-478-2050
-----------------------------------------------------
Fax | 787-764-7796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL BERETTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-478-2050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | TC AMB 597
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------