Provider Demographics
NPI:1497839716
Name:BEACON OF LIFE AMBULANCE SERVICE
Entity Type:Organization
Organization Name:BEACON OF LIFE AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:OUIDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-237-1767
Mailing Address - Street 1:109 S. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333
Mailing Address - Country:US
Mailing Address - Phone:276-237-7167
Mailing Address - Fax:276-236-4725
Practice Address - Street 1:16559 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:VA
Practice Address - Zip Code:24283
Practice Address - Country:US
Practice Address - Phone:276-237-7167
Practice Address - Fax:276-236-4725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA190001397Medicare ID - Type Unspecified