=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609094887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WANTAGH-LEVITTOWN VOLUNTEER AMBULANCE CORPS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 BALSAM LN
-----------------------------------------------------
City | LEVITTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11756-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-731-1485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 BALSAM LN
-----------------------------------------------------
City | LEVITTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11756-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-731-1485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TRUSTEE
-----------------------------------------------------
Name | MR. DON GRIMALDI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-731-1485
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 2933
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------