Provider Demographics
NPI:1891382198
Name:LEVINE, MADISON CARLY (EMT)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:CARLY
Last Name:LEVINE
Suffix:
Gender:F
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 CABRILLO ST APT D
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3122
Mailing Address - Country:US
Mailing Address - Phone:949-878-8180
Mailing Address - Fax:
Practice Address - Street 1:600 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-2106
Practice Address - Country:US
Practice Address - Phone:949-600-8100
Practice Address - Fax:949-600-8101
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE158274146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE158274OtherEMT CENTRAL REGISTRY