Provider Demographics
NPI:1093743775
Name:LIBERTY COUNTY AMBULANCE SERVICE
Entity Type:Organization
Organization Name:LIBERTY COUNTY AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PIPPIN
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:850-643-5866
Mailing Address - Street 1:12503 NW VIRGINIA G WEAVER ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321-0399
Mailing Address - Country:US
Mailing Address - Phone:850-643-5866
Mailing Address - Fax:850-643-2866
Practice Address - Street 1:12503 NW VIRGINIA G WEAVER ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-0399
Practice Address - Country:US
Practice Address - Phone:850-643-5866
Practice Address - Fax:850-643-2866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL002611146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA0202Medicare ID - Type UnspecifiedAMBULANCE