Provider Demographics
NPI:1073553822
Name:POND HILL LILY LAKE AMBULANCE ASSOCIATION
Entity Type:Organization
Organization Name:POND HILL LILY LAKE AMBULANCE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAPTAIN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:I
Authorized Official - Last Name:BALLIET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-379-2292
Mailing Address - Street 1:421 POND HILL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:WAPWALLOPEN
Mailing Address - State:PA
Mailing Address - Zip Code:18660-1214
Mailing Address - Country:US
Mailing Address - Phone:570-379-2292
Mailing Address - Fax:570-379-2292
Practice Address - Street 1:421 POND HILL MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:WAPWALLOPEN
Practice Address - State:PA
Practice Address - Zip Code:18660-1214
Practice Address - Country:US
Practice Address - Phone:570-379-2292
Practice Address - Fax:570-379-2292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103047580001Medicaid
PA610492700OtherFEDERAL BLACK LUNG PROGRA
PA289707OtherACCESS CARE II PPO
PA998574OtherBLUE CROSS NEPA MAJ MED
PA998574OtherBLUE CROSS NEPA MAJ MED