Provider Demographics
NPI:1336242601
Name:LIBERTY COUNTY EMERGENCY MEDICAL SERVICES INC
Entity Type:Organization
Organization Name:LIBERTY COUNTY EMERGENCY MEDICAL SERVICES INC
Other - Org Name:HULL DAISETTA VOL. AMBULANCE SERVICE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-536-3080
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:TX
Mailing Address - Zip Code:77564-0351
Mailing Address - Country:US
Mailing Address - Phone:936-536-3080
Mailing Address - Fax:936-536-6519
Practice Address - Street 1:114 MAIN ST.
Practice Address - Street 2:
Practice Address - City:DAISETTA
Practice Address - State:TX
Practice Address - Zip Code:77533
Practice Address - Country:US
Practice Address - Phone:936-536-3080
Practice Address - Fax:936-536-6519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146013341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX517216OtherBCBS
TX000519101Medicaid
LA1161942Medicaid
TX517216OtherBCBS