Provider Demographics
NPI:1134316284
Name:BASIC LIFE SUPPORT, INC.
Entity Type:Organization
Organization Name:BASIC LIFE SUPPORT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-559-3616
Mailing Address - Street 1:2250 HIWAY 95
Mailing Address - Street 2:#556
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-9013
Mailing Address - Country:US
Mailing Address - Phone:760-559-3616
Mailing Address - Fax:
Practice Address - Street 1:2250 HIWAY 95
Practice Address - Street 2:#556
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-9013
Practice Address - Country:US
Practice Address - Phone:760-559-3616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD05399766343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ192341OtherAHCCCS