Provider Demographics
NPI:1679648877
Name:BLAKELY BOROUGH COMMUNITY AMBULANCE ASSOCIATION
Entity type:Organization
Organization Name:BLAKELY BOROUGH COMMUNITY AMBULANCE ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUCIANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-241-6828
Mailing Address - Street 1:PO BOX 1846
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-0846
Mailing Address - Country:US
Mailing Address - Phone:570-714-3694
Mailing Address - Fax:570-714-3695
Practice Address - Street 1:500 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:PECKVILLE
Practice Address - State:PA
Practice Address - Zip Code:18452-1604
Practice Address - Country:US
Practice Address - Phone:570-307-1279
Practice Address - Fax:570-307-1275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA040613416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA287403OtherFREEDOM BLUE
899215OtherFEDERAL BLACK LUNG
PA0012562900002Medicaid
899215OtherFEDERAL BLACK LUNG