Provider Demographics
NPI:1265434690
Name:GRANBY AMBULANCE ASSOCIATION, INCORPORATED
Entity type:Organization
Organization Name:GRANBY AMBULANCE ASSOCIATION, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESTIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:DIBATTISTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-653-6535
Mailing Address - Street 1:1 PEGVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06035-1615
Mailing Address - Country:US
Mailing Address - Phone:860-653-6535
Mailing Address - Fax:888-965-4620
Practice Address - Street 1:1 PEGVILLE ROAD
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06035-1615
Practice Address - Country:US
Practice Address - Phone:860-653-6535
Practice Address - Fax:888-965-4620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3416L0300X
CTC056B1341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
204062000OtherDEPT OF LABOR
CT004149739Medicaid
706607OtherCONNECTICARE
590010949OtherRAILROAD MEDICARE
CT710C056B1CT01OtherANTHEM BCBS
00414973900OtherBLUE CARE FAMILY
=========OtherTRICARE