Provider Demographics
NPI:1053870451
Name:LIFEPOINT AMBULANCE LLC
Entity type:Organization
Organization Name:LIFEPOINT AMBULANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:CHANCE
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:AMBULANCE SERVICE
Authorized Official - Phone:478-714-3612
Mailing Address - Street 1:1011 HWY 341 NORTH
Mailing Address - Street 2:SUITE 20 A
Mailing Address - City:ROBERTA
Mailing Address - State:GA
Mailing Address - Zip Code:31078
Mailing Address - Country:US
Mailing Address - Phone:478-714-3612
Mailing Address - Fax:
Practice Address - Street 1:1011 HWY 341 NORTH
Practice Address - Street 2:SUITE 20 A
Practice Address - City:ROBERTA
Practice Address - State:GA
Practice Address - Zip Code:31078
Practice Address - Country:US
Practice Address - Phone:478-714-3612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport