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General NPI Number Information
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NPI Number | 1427475854
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Entity Type | Organization
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Legal Business Name | RAQUETTE LAKE VOLUNTEER AMBULANCE SQUAD INC
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Dates
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Enumeration Date | 03/24/2014
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Last Update Date | 03/24/2014
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Provider Practice Location Address
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Address Line | 171 ROUTE 28
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City | RAQUETTE LAKE
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State | NY
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Zip | 13436-0125
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Country | US
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Telephone | 315-354-4644
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Fax | 315-354-4228
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Provider Business Mailing Address
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Address Line | PO BOX 125
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City | RAQUETTE LAKE
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State | NY
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Zip | 13436-0125
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Country | US
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Telephone | 315-354-4644
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Fax | 315-354-4228
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MR. CORKY RISLEY
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Credential |
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Telephone | 315-723-9041
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3416L0300X
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Taxonomy Name | Land Ambulance
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License Number | 1086
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License Number State | NY
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