Provider Demographics
NPI:1659318517
Name:LIFE AIR RESCUE
Entity Type:Organization
Organization Name:LIFE AIR RESCUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FLIGHT NURSE
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-681-4610
Mailing Address - Street 1:PO BOX 37103
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71133-7103
Mailing Address - Country:US
Mailing Address - Phone:318-681-4610
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT MARY PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4343
Practice Address - Country:US
Practice Address - Phone:318-681-4610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA91100263416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1675458Medicaid
LAB8086OtherBLUE CROSS/BLUE SHIELD
LA1675458Medicaid
LAB8086OtherBLUE CROSS/BLUE SHIELD