Provider Demographics
NPI:1881747384
Name:BRISTOL RESCUE SQUAD, INC.
Entity type:Organization
Organization Name:BRISTOL RESCUE SQUAD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-453-2472
Mailing Address - Street 1:PO BOX 227
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:05443-0227
Mailing Address - Country:US
Mailing Address - Phone:802-453-2472
Mailing Address - Fax:
Practice Address - Street 1:45 MONKTON ROAD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VT
Practice Address - Zip Code:05443
Practice Address - Country:US
Practice Address - Phone:802-453-2513
Practice Address - Fax:802-453-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X
VT07013416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006440Medicaid
VTVT6440OtherPRIVATE INSURANCES
VT0006440Medicaid