Provider Demographics
NPI:1114007663
Name:RUSTON LINCOLN AMBULANCE
Entity Type:Organization
Organization Name:RUSTON LINCOLN AMBULANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF EMS
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-251-8628
Mailing Address - Street 1:PO BOX 2069
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-2069
Mailing Address - Country:US
Mailing Address - Phone:318-251-8607
Mailing Address - Fax:318-747-9994
Practice Address - Street 1:920 E GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3937
Practice Address - Country:US
Practice Address - Phone:318-251-8628
Practice Address - Fax:318-747-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA91100523416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1122459Medicaid
LA13466OtherBLUE CROSS BLUE SHIELD LA
LA1122459Medicaid
LA47297Medicare ID - Type UnspecifiedMEDICARE