Provider Demographics
NPI:1093776775
Name:PC ON BOARD, LLC
Entity Type:Organization
Organization Name:PC ON BOARD, LLC
Other - Org Name:HART'S AMBULETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAUREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MEDVICK-TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-332-3911
Mailing Address - Street 1:3134 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-9280
Mailing Address - Country:US
Mailing Address - Phone:419-332-3911
Mailing Address - Fax:419-332-3820
Practice Address - Street 1:3134 E STATE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-9280
Practice Address - Country:US
Practice Address - Phone:419-332-3911
Practice Address - Fax:419-332-3820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHMTB-1051343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61101OtherHUMANA
OH734548OtherBUCKYE COMMUNITY HEALTH
OH2549871Medicaid