Provider Demographics
NPI:1891126652
Name:COASTAL LIFE AMBULANCE, INC.
Entity Type:Organization
Organization Name:COASTAL LIFE AMBULANCE, INC.
Other - Org Name:EASTBOUND & DOWN, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CLAIR
Authorized Official - Last Name:BRUSSEAU
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:916-871-8487
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-0005
Mailing Address - Country:US
Mailing Address - Phone:888-935-5525
Mailing Address - Fax:
Practice Address - Street 1:415 ROBERTSON BLVD STE B
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-5713
Practice Address - Country:US
Practice Address - Phone:888-935-5525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-04
Last Update Date:2014-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport