Provider Demographics
NPI:1750498440
Name:EASTWEST PROTO INC
Entity Type:Organization
Organization Name:EASTWEST PROTO INC
Other - Org Name:LIFELINE AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GENADY
Authorized Official - Middle Name:
Authorized Official - Last Name:GORIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-335-2980
Mailing Address - Street 1:1120 S MAPLE AVE
Mailing Address - Street 2:SUITE #200
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640
Mailing Address - Country:US
Mailing Address - Phone:323-832-0760
Mailing Address - Fax:323-832-0781
Practice Address - Street 1:1120 S MAPLE AVE
Practice Address - Street 2:SUITE #200
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640
Practice Address - Country:US
Practice Address - Phone:323-832-0760
Practice Address - Fax:323-832-0781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACHP1832341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTE01106FMedicaid
CAZ524Medicare PIN