Provider Demographics
NPI:1578527800
Name:LORAIN LIFECARE AMBULANCE SERVICE INC
Entity Type:Organization
Organization Name:LORAIN LIFECARE AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDRE DE LA PORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-323-6111
Mailing Address - Street 1:640 CLEVELAND STREET
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-4104
Mailing Address - Country:US
Mailing Address - Phone:440-323-6111
Mailing Address - Fax:440-365-2266
Practice Address - Street 1:109 W. 23RD STREET
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-4801
Practice Address - Country:US
Practice Address - Phone:440-244-2336
Practice Address - Fax:440-244-1012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X
OH470092341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0689401Medicaid
OH9224741Medicare ID - Type Unspecified