Provider Demographics
NPI:1225015738
Name:PENNS CREEK AMBULANCE CLUB
Entity Type:Organization
Organization Name:PENNS CREEK AMBULANCE CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-837-3407
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:PENNS CREEK
Mailing Address - State:PA
Mailing Address - Zip Code:17862-0125
Mailing Address - Country:US
Mailing Address - Phone:570-837-1943
Mailing Address - Fax:
Practice Address - Street 1:704 TROXELVILLE RD
Practice Address - Street 2:
Practice Address - City:PENNS CREEK
Practice Address - State:PA
Practice Address - Zip Code:17862
Practice Address - Country:US
Practice Address - Phone:570-837-3407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012246700001Medicaid
PA216058Medicare PIN