Provider Demographics
NPI:1649258211
Name:LAKEWOOD COMMUNITY AMBULANCE SERVICE
Entity type:Organization
Organization Name:LAKEWOOD COMMUNITY AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-367-4768
Mailing Address - Street 1:1701 LAKE LANSING RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912
Mailing Address - Country:US
Mailing Address - Phone:517-485-0001
Mailing Address - Fax:517-485-1138
Practice Address - Street 1:270 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:MI
Practice Address - Zip Code:48897-9798
Practice Address - Country:US
Practice Address - Phone:269-367-4453
Practice Address - Fax:269-367-4453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI341007146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2796804Medicaid