Provider Demographics
NPI:1912910092
Name:LIFESTAR AMBULANCE, INC.
Entity Type:Organization
Organization Name:LIFESTAR AMBULANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:TARR
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CRTT
Authorized Official - Phone:410-546-0809
Mailing Address - Street 1:1024 S TOWER DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-6474
Mailing Address - Country:US
Mailing Address - Phone:410-546-0809
Mailing Address - Fax:410-860-5260
Practice Address - Street 1:1024 S TOWER DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6474
Practice Address - Country:US
Practice Address - Phone:410-546-0809
Practice Address - Fax:410-860-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD063341600000X
MD2204343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE00141515Medicaid
DE00141515Medicaid
DE490470Medicare PIN