Provider Demographics
NPI:1336172790
Name:EASTERN AMBULANCE SERVICE, LLC
Entity Type:Organization
Organization Name:EASTERN AMBULANCE SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FACKOVEC
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:781-569-6003
Mailing Address - Street 1:PO BOX 3009
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01888-1809
Mailing Address - Country:US
Mailing Address - Phone:781-569-6003
Mailing Address - Fax:781-569-6007
Practice Address - Street 1:12 WALNUT HILL PARK
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-3714
Practice Address - Country:US
Practice Address - Phone:781-569-6003
Practice Address - Fax:781-569-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39943416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1719289Medicaid
MA1719289Medicaid
MAAM0228Medicare PIN