MEDICARE: LIFE-FORCE AMBULANCE, 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	3416L0300X	Land Ambulance		GA

General Provider Information

NPI Number	:	1487957387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE-FORCE AMBULANCE, INC.

Provider Business Mailing Address
First Line	:	361 W MEMORIAL DR
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-4136
Country	:	US
Telephone Number	:	770-693-8692
Fax Number	:	678-401-5833

Provider Business Practice Location Address
First Line	:	361 W MEMORIAL DR
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-4136
Country	:	US
Telephone Number	:	770-693-8692
Fax Number	:	678-401-5833

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. ROGER C BURGESS
Credential	:	NREMT-I85
Telephone Number	:	770-693-8692

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	12/15/2010

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