Provider Demographics
NPI:1659321206
Name:LIFELINE AMBULANCE SERVICE, LLC
Entity Type:Organization
Organization Name:LIFELINE AMBULANCE SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-953-6870
Mailing Address - Street 1:11 STATE ST
Mailing Address - Street 2:A
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-2050
Mailing Address - Country:US
Mailing Address - Phone:781-953-6870
Mailing Address - Fax:781-646-0020
Practice Address - Street 1:11 STATE ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-2050
Practice Address - Country:US
Practice Address - Phone:781-935-2220
Practice Address - Fax:781-935-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3100341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1700197Medicaid
MA1700197Medicaid