Provider Demographics
NPI:1598719734
Name:ALTAVISTA LIFE SAVING AND FIRST AID CREW, INCORPORATED
Entity Type:Organization
Organization Name:ALTAVISTA LIFE SAVING AND FIRST AID CREW, INCORPORATED
Other - Org Name:ALTAVISTA EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRADNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-369-4716
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:1510 MAIN STREET
Mailing Address - City:ALTAVISTA
Mailing Address - State:VA
Mailing Address - Zip Code:24517
Mailing Address - Country:US
Mailing Address - Phone:434-369-4716
Mailing Address - Fax:434-369-4306
Practice Address - Street 1:1510 MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTAVISTA
Practice Address - State:VA
Practice Address - Zip Code:24517
Practice Address - Country:US
Practice Address - Phone:434-369-4716
Practice Address - Fax:434-369-4306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA126341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance