Provider Demographics
NPI:1366499527
Name:LIFE EMS OF IONIA CO INC
Entity Type:Organization
Organization Name:LIFE EMS OF IONIA CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:MEIJER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-242-8805
Mailing Address - Street 1:1275 CEDAR ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1378
Mailing Address - Country:US
Mailing Address - Phone:616-458-0042
Mailing Address - Fax:616-242-8825
Practice Address - Street 1:350 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-1543
Practice Address - Country:US
Practice Address - Phone:616-527-9125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE EMS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-30
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6210083416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3204560Medicaid
MIOM14980Medicare ID - Type Unspecified