Provider Demographics
NPI:1679019541
Name:LUCKY AMBULETTE SERVICES
Entity type:Organization
Organization Name:LUCKY AMBULETTE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUCKO
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-741-1895
Mailing Address - Street 1:205 GIBBS POND RD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2265
Mailing Address - Country:US
Mailing Address - Phone:631-432-9691
Mailing Address - Fax:631-257-5866
Practice Address - Street 1:205 GIBBS POND RD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2265
Practice Address - Country:US
Practice Address - Phone:631-432-9691
Practice Address - Fax:631-257-5866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY39758343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04582707Medicaid