Provider Demographics
NPI:1851391601
Name:EAST LYME AMBULANCE FUND INC
Entity Type:Organization
Organization Name:EAST LYME AMBULANCE FUND INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-739-3449
Mailing Address - Street 1:269 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2302
Mailing Address - Country:US
Mailing Address - Phone:860-638-1800
Mailing Address - Fax:860-638-1802
Practice Address - Street 1:8 GRAND ST
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-3204
Practice Address - Country:US
Practice Address - Phone:860-739-3449
Practice Address - Fax:860-739-5268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
710C045A2CT01OtherBLUE CROSS/BLUE SHIELD
CU8738OtherHEALTHNET
CT004195807Medicaid
CT004195807Medicaid