Provider Demographics
NPI:1457300741
Name:ILDEFONSO SANTIAGO AYALA
Entity Type:Organization
Organization Name:ILDEFONSO SANTIAGO AYALA
Other - Org Name:MEDLIFE AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ILDEFONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO AYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-255-0636
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-1847
Mailing Address - Country:US
Mailing Address - Phone:787-255-0636
Mailing Address - Fax:
Practice Address - Street 1:102 CALLE PARQUE W
Practice Address - Street 2:MONTE GRANDE
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623-3735
Practice Address - Country:US
Practice Address - Phone:787-255-0636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-06
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTC AMB 3103416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0056627Medicare ID - Type UnspecifiedAMBULANCE LAND