=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720411978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFEQUEST AMBULANCE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2013
-----------------------------------------------------
Last Update Date | 08/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 RIVER RD 306
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-3499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-542-8184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 RIVER RD 306
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-3499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-542-8184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILFORD CONSTANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 862-218-8468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------