=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609574433
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHADDAI AMBULANCE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2023
-----------------------------------------------------
Last Update Date | 02/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BO HIGUERO CARR 150 KM 7.3
-----------------------------------------------------
City | VILLALBA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-397-7615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HC 2 BOX 4467
-----------------------------------------------------
City | VILLALBA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00766-9757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-397-7615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ALEJANDRO DE JESUS BURGOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-397-7615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------