Provider Demographics
NPI:1477598092
Name:JACKSON TOWNSHIP VOLUNTEER AMBULANCE ASSOCIATION
Entity Type:Organization
Organization Name:JACKSON TOWNSHIP VOLUNTEER AMBULANCE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TITUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-696-4544
Mailing Address - Street 1:PO BOX 582
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-0582
Mailing Address - Country:US
Mailing Address - Phone:570-696-4544
Mailing Address - Fax:
Practice Address - Street 1:1160 CHASE RD
Practice Address - Street 2:
Practice Address - City:SHAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18708-9504
Practice Address - Country:US
Practice Address - Phone:570-696-4544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012771640001Medicaid
PA221083Medicare PIN