Provider Demographics
NPI:1780639823
Name:LIFESTAR AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:LIFESTAR AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-532-2474
Mailing Address - Street 1:940 N ELM ST
Mailing Address - Street 2:PO BOX 1838
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-2326
Mailing Address - Country:US
Mailing Address - Phone:618-532-2474
Mailing Address - Fax:618-532-7795
Practice Address - Street 1:528 S WEST ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2873
Practice Address - Country:US
Practice Address - Phone:217-245-7540
Practice Address - Fax:217-243-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3633341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========011Medicaid
IL=========011Medicaid