=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811265168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SQUAD A, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2011
-----------------------------------------------------
Last Update Date | 04/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10075 SANDMEYER LN SUITE D
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19116-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-677-3775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10075 SANDMEYER LN SUITE D
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19116-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRS.
-----------------------------------------------------
Name | DAVID MAMIKONYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-677-3775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------