=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679546857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHBURY AMBULANCE ASSOCIATION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2006
-----------------------------------------------------
Last Update Date | 03/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 68 GEORGES HILL RD
-----------------------------------------------------
City | SOUTHBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06488-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-262-8082
-----------------------------------------------------
Fax | 203-262-8082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 269 MAIN ST
-----------------------------------------------------
City | CROMWELL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06416-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-638-1800
-----------------------------------------------------
Fax | 860-638-1802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HENRY VELTHUIZEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-262-8082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------