Provider Demographics
NPI:1205996246
Name:ARIZONA AMBULANCE OF DOUGLAS INC
Entity type:Organization
Organization Name:ARIZONA AMBULANCE OF DOUGLAS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN HORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-578-9526
Mailing Address - Street 1:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85636-1988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4266 E INDUSTRY DRIVE
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635
Practice Address - Country:US
Practice Address - Phone:520-459-4040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ590014363OtherRR MEDICARE
AZAZ0152110OtherBCBS
AZ189840100OtherDEPT OF LABOR
AZ536237-01Medicaid
AZAZ0000D100066OtherTRAILBLAZER HEALTH
AZ590014363OtherRR MEDICARE