MEDICARE: FORTY FORT COMMUNITY AMBULANCE ASSOCIATION

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	3416L0300X	Land Ambulance	05168	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	800360	OTHER		FEDERAL BLACK LUNG

General Provider Information

NPI Number	:	1215005897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORTY FORT COMMUNITY AMBULANCE ASSOCIATION

Provider Business Mailing Address
First Line	:	PO BOX 1846
Second Line	:
City	:	SHAVERTOWN
State	:	PA
Zip	:	18708-0846
Country	:	US
Telephone Number	:	570-714-3694
Fax Number	:

Provider Business Practice Location Address
First Line	:	1271 WYOMING AVE
Second Line	:
City	:	FORTY FORT
State	:	PA
Zip	:	18704-4101
Country	:	US
Telephone Number	:	570-288-1671
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DIANE OHARA
Credential	:
Telephone Number	:	570-288-1671

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	08/22/2020

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