Provider Demographics
NPI:1184037616
Name:PEACH STATE EMS, LLC
Entity Type:Organization
Organization Name:PEACH STATE EMS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:STANCLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:678-828-1250
Mailing Address - Street 1:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-0010
Mailing Address - Country:US
Mailing Address - Phone:888-838-1391
Mailing Address - Fax:888-391-8501
Practice Address - Street 1:11335 LEWIS BRASELTON BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-3288
Practice Address - Country:US
Practice Address - Phone:888-838-1391
Practice Address - Fax:888-391-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA078-043416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA078-04OtherGA STATE EMS LICENSE NUMBER