Provider Demographics
NPI:1114947322
Name:LIFESTAR AMBULANCE SERVICE INC.
Entity Type:Organization
Organization Name:LIFESTAR AMBULANCE SERVICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:JR
Authorized Official - Credentials:NREMT-P
Authorized Official - Phone:434-634-1144
Mailing Address - Street 1:300 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23847-1608
Mailing Address - Country:US
Mailing Address - Phone:434-634-1144
Mailing Address - Fax:434-634-1155
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1608
Practice Address - Country:US
Practice Address - Phone:434-634-1144
Practice Address - Fax:434-634-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA432381OtherANTHEM BLUE CROSS