MEDICARE: HERITAGE VILLAGE AMBULANCE ASSOCIATION 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	CV2214	OTHER	HEALTHNET
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	710C130C2CT01	OTHER	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1891796405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE VILLAGE AMBULANCE ASSOCIATION INC

Provider Business Mailing Address
First Line	:	269 MAIN ST
Second Line	:
City	:	CROMWELL
State	:	CT
Zip	:	06416-2302
Country	:	US
Telephone Number	:	860-638-1800
Fax Number	:	860-638-1802

Provider Business Practice Location Address
First Line	:	588 EAST HILL ROAD
Second Line	:
City	:	SOUTHBURY
State	:	CT
Zip	:	06488-1389
Country	:	US
Telephone Number	:	203-264-9543
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KEN PELLETIER
Credential	:
Telephone Number	:	203-264-9543

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	08/13/2012

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