=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578562047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESTAR AMBULANCE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2005
-----------------------------------------------------
Last Update Date | 04/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1402 LAGRANGE ST
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43608-2928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-245-6210
-----------------------------------------------------
Fax | 419-245-7003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1402 LAGRANGE ST
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43608-2928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-245-6210
-----------------------------------------------------
Fax | 419-251-7003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. CATHY NELSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-245-6210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 480049
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------