Provider Demographics
NPI:1891773909
Name:COUDERSPORT VOLUNTEER AMBULANCE ASSOCIATION
Entity Type:Organization
Organization Name:COUDERSPORT VOLUNTEER AMBULANCE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - BOARD OF DIRECTORS
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-274-7411
Mailing Address - Street 1:PO BOX 651
Mailing Address - Street 2:
Mailing Address - City:COUDERSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16915-0651
Mailing Address - Country:US
Mailing Address - Phone:814-274-7411
Mailing Address - Fax:814-274-9344
Practice Address - Street 1:122 E 2ND ST
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915-1750
Practice Address - Country:US
Practice Address - Phone:814-274-7411
Practice Address - Fax:814-274-9344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA002313416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA590004818OtherRR MEDICARE/PALMETTO GBA
PA288959OtherBLUE CROSS/BLUE SHIELD
PA0007005190005Medicaid
PA0007005190005Medicaid
PA0007005190005Medicaid