Provider Demographics
NPI:1093921629
Name:LANIER COUNTY AMBULANCE SERVICE
Entity Type:Organization
Organization Name:LANIER COUNTY AMBULANCE SERVICE
Other - Org Name:LANIER COUNTY AMBULANCE SERVICE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GINTY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:229-482-8402
Mailing Address - Street 1:PO BOX 5888
Mailing Address - Street 2:ATTN: PFS DEPT.
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-5888
Mailing Address - Country:US
Mailing Address - Phone:229-482-8402
Mailing Address - Fax:229-482-8539
Practice Address - Street 1:116 W THIGPEN AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:GA
Practice Address - Zip Code:31635-1006
Practice Address - Country:US
Practice Address - Phone:229-482-8401
Practice Address - Fax:229-482-8539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA08601341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAHOSP110OtherCAHABA
GA000001163AMedicaid
GA000001163BMedicaid
GA000001163HMedicaid