Provider Demographics
NPI:1386195311
Name:ADVANCED LIFE SUPPORT CORP.
Entity Type:Organization
Organization Name:ADVANCED LIFE SUPPORT CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAWIA
Authorized Official - Middle Name:BAKRI
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-207-9284
Mailing Address - Street 1:PO BOX 6101
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22403-6101
Mailing Address - Country:US
Mailing Address - Phone:540-207-9287
Mailing Address - Fax:540-898-8138
Practice Address - Street 1:11905 MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-7326
Practice Address - Country:US
Practice Address - Phone:540-207-9284
Practice Address - Fax:540-898-8138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA166343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)