Provider Demographics
NPI:1073662805
Name:DEEP SOUTH AMBULANCE SERVICE, INC
Entity Type:Organization
Organization Name:DEEP SOUTH AMBULANCE SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:229-482-2899
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:37 PEACHTREE ST
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-0067
Mailing Address - Country:US
Mailing Address - Phone:229-482-2899
Mailing Address - Fax:
Practice Address - Street 1:37 PEACHTREE STREET
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:GA
Practice Address - Zip Code:31635-0067
Practice Address - Country:US
Practice Address - Phone:229-482-2899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA086-023416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00432528AMedicaid
GA590005817Medicare ID - Type UnspecifiedPALMETTO MEDICARE AMBULAN
GA00432528AMedicaid