Provider Demographics
NPI:1073750766
Name:BREWERTON VOLUNTEER FIRE DEPARTMENT AMBULANCE INC
Entity Type:Organization
Organization Name:BREWERTON VOLUNTEER FIRE DEPARTMENT AMBULANCE INC
Other - Org Name:BREWERTON AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAILLOUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-427-8149
Mailing Address - Street 1:PO BOX 535
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-0535
Mailing Address - Country:US
Mailing Address - Phone:315-635-1789
Mailing Address - Fax:315-635-3289
Practice Address - Street 1:9625 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:BREWERTON
Practice Address - State:NY
Practice Address - Zip Code:13029-0708
Practice Address - Country:US
Practice Address - Phone:315-668-9789
Practice Address - Fax:315-428-8648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113193416L0300X
NY318653416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03122016Medicaid
NY53976BMedicare PIN