Provider Demographics
NPI:1013952589
Name:ROCKFORD AMBULANCE INC
Entity Type:Organization
Organization Name:ROCKFORD AMBULANCE INC
Other - Org Name:LOWELL AMBULANCE, SPARTA AMBULANCE, GRAND RAPIDS TWP. AMBULANCE
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RISSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-866-0724
Mailing Address - Street 1:8450 SHANER AVE. NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341
Mailing Address - Country:US
Mailing Address - Phone:616-866-0724
Mailing Address - Fax:616-866-3903
Practice Address - Street 1:8450 SHANER AVE NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9379
Practice Address - Country:US
Practice Address - Phone:616-866-0724
Practice Address - Fax:616-866-3903
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROCKFORD AMBULANCE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-18
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3416L0300X
MI4110043416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI590D10018OtherBLUE CROSS BLUE SHIELD
MI3001478Medicaid
MI590058353OtherRAILROAD MEDICARE
MI0D10018Medicare PIN