Provider Demographics
NPI:1043344674
Name:CHINCHILLA HOSE COMPANY OF SOUTH ABINGTON TOWNSHIP
Entity Type:Organization
Organization Name:CHINCHILLA HOSE COMPANY OF SOUTH ABINGTON TOWNSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-586-5626
Mailing Address - Street 1:113 SHADY LANE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9020
Mailing Address - Country:US
Mailing Address - Phone:570-586-5726
Mailing Address - Fax:
Practice Address - Street 1:113 SHADY LANE RD
Practice Address - Street 2:
Practice Address - City:SOUTH ABINGTON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18411-9020
Practice Address - Country:US
Practice Address - Phone:570-586-5726
Practice Address - Fax:570-587-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X
PA350043416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA590009247OtherRAILROAD MEDICARE
PA0012904890001Medicaid
PA081105900OtherFEDERAL BLUE CROSS