Provider Demographics
NPI:1043214372
Name:LIFE LINE AMBULANCE SERVICE INC
Entity Type:Organization
Organization Name:LIFE LINE AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP OF REVENUE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:833-703-2294
Mailing Address - Street 1:PO BOX 847102
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7102
Mailing Address - Country:US
Mailing Address - Phone:800-913-9106
Mailing Address - Fax:
Practice Address - Street 1:909 HINMAN ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305
Practice Address - Country:US
Practice Address - Phone:928-445-3814
Practice Address - Fax:928-778-1477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZEMS2878341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ070136Medicaid
AZ860222371Medicare PIN