=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467425652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERFORD AMBULANCE SERVICE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2006
-----------------------------------------------------
Last Update Date | 05/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 454 BOSTON POST RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06385-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-477-9301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 454 BOSTON POST RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06385-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-477-9301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. NEIL WISEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-389-2701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------