=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538395389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDEN EMERGENCY SQUAD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2009
-----------------------------------------------------
Last Update Date | 04/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2795 E CHURCH ST
-----------------------------------------------------
City | EDEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14057-1280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-992-4460
-----------------------------------------------------
Fax | 716-992-2068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 290184
-----------------------------------------------------
City | WETHERSFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06129-0184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-257-7080
-----------------------------------------------------
Fax | 860-563-3403
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED AGENT
-----------------------------------------------------
Name | MRS. MARY T GENTILE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-257-7080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 1447
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------