Provider Demographics
NPI:1780895185
Name:CAPITAL CITY AMBULANCE, LLC
Entity type:Organization
Organization Name:CAPITAL CITY AMBULANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMORODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-220-1377
Mailing Address - Street 1:19573 E IDA PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-5177
Mailing Address - Country:US
Mailing Address - Phone:720-220-1377
Mailing Address - Fax:303-671-0237
Practice Address - Street 1:19573 E IDA PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-5177
Practice Address - Country:US
Practice Address - Phone:720-220-1377
Practice Address - Fax:303-671-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1014313341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31982557Medicaid
CO31982557Medicaid