Provider Demographics
NPI:1831317486
Name:LIFESTAR AMBULETTE, INC.
Entity Type:Organization
Organization Name:LIFESTAR AMBULETTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:VASSALLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:602-957-2800
Mailing Address - Street 1:1501 W FOUNTAINHEAD PKWY STE 650
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1864
Mailing Address - Country:US
Mailing Address - Phone:602-957-2800
Mailing Address - Fax:602-275-7886
Practice Address - Street 1:1501 W FOUNTAINHEAD PKWY STE 650
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1864
Practice Address - Country:US
Practice Address - Phone:602-957-2800
Practice Address - Fax:602-275-7886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ333435Medicaid