Provider Demographics
NPI:1326560947
Name:QUALITY CARE LOGISTICS AMBULANCE SERVICE LLC
Entity Type:Organization
Organization Name:QUALITY CARE LOGISTICS AMBULANCE SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-613-3316
Mailing Address - Street 1:185 ARROWHEAD LN
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-5371
Mailing Address - Country:US
Mailing Address - Phone:276-613-3316
Mailing Address - Fax:
Practice Address - Street 1:2796 EAST LEE HIGHWAY
Practice Address - Street 2:
Practice Address - City:MAX MEADOWS
Practice Address - State:VA
Practice Address - Zip Code:24360
Practice Address - Country:US
Practice Address - Phone:276-613-3316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========Medicaid