Provider Demographics
NPI:1760534036
Name:ONTARIO COUNTY ADVANCED LIFE SUPPORT, INC
Entity Type:Organization
Organization Name:ONTARIO COUNTY ADVANCED LIFE SUPPORT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-396-6672
Mailing Address - Street 1:350 PARRISH ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1731
Mailing Address - Country:US
Mailing Address - Phone:585-396-6672
Mailing Address - Fax:585-396-0154
Practice Address - Street 1:233 N PEARL ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1439
Practice Address - Country:US
Practice Address - Phone:585-396-6672
Practice Address - Fax:585-396-0154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3496341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01895192Medicaid
NYP0100637ALOtherBLUE CHOICE
NY104405FYOtherPREFERRED CARE #
NY104405FYOtherPREFERRED CARE #
NYCC4372Medicare ID - Type Unspecified