MEDICARE: BASIC LIFE SUPPORT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)	D05399766	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	192341	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1134316284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BASIC LIFE SUPPORT, INC.

Provider Business Mailing Address
First Line	:	2250 HIWAY 95
Second Line	:	#556
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-9013
Country	:	US
Telephone Number	:	760-559-3616
Fax Number	:

Provider Business Practice Location Address
First Line	:	2250 HIWAY 95
Second Line	:	#556
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-9013
Country	:	US
Telephone Number	:	760-559-3616
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT J HALL
Credential	:
Telephone Number	:	760-559-3616

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	10/02/2007

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Directions to “BASIC LIFE SUPPORT, INC. ” Practice Location

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