MEDICARE: OLD LYME SOUTH END VOLUNTEER AMBULANCE

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	341600000X	Ambulance	C105B1	CT

General Provider Information

NPI Number	:	1437149994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD LYME SOUTH END VOLUNTEER AMBULANCE

Provider Business Mailing Address
First Line	:	PO BOX 290184
Second Line	:
City	:	WETHERSFIELD
State	:	CT
Zip	:	06129-0184
Country	:	US
Telephone Number	:	860-257-9201
Fax Number	:	860-721-6362

Provider Business Practice Location Address
First Line	:	22 CROSS LN
Second Line	:
City	:	OLD LYME
State	:	CT
Zip	:	06371-2115
Country	:	US
Telephone Number	:	860-434-0089
Fax Number	:	860-434-8052

Authorized Official
Title or Position	:	AUTHORIZED AGENT
Name	:	MS. MARY T GENTILE
Credential	:
Telephone Number	:	860-257-9201

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	03/13/2008

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