Provider Demographics
NPI:1992851638
Name:LIFE LINE MEDICAL AMBULANCE
Entity Type:Organization
Organization Name:LIFE LINE MEDICAL AMBULANCE
Other - Org Name:CONNIE SCARBROUGH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCARBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-768-4000
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:200 CENTER STREET
Mailing Address - City:FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:43321
Mailing Address - Country:US
Mailing Address - Phone:419-768-4000
Mailing Address - Fax:419-864-3967
Practice Address - Street 1:200 CENTER STREET
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:OH
Practice Address - Zip Code:43321
Practice Address - Country:US
Practice Address - Phone:419-768-4000
Practice Address - Fax:419-864-3967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0213941Medicaid
OH0213941Medicaid