Provider Demographics
NPI:1023048261
Name:KILLINGWORTH AMBULANCE ASSOCIATION, INC
Entity type:Organization
Organization Name:KILLINGWORTH AMBULANCE ASSOCIATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:O'SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-663-2450
Mailing Address - Street 1:195 ROUTE 80
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419-1400
Mailing Address - Country:US
Mailing Address - Phone:860-663-3634
Mailing Address - Fax:860-663-3795
Practice Address - Street 1:325 ROUTE 81
Practice Address - Street 2:
Practice Address - City:KILLINGWORTH
Practice Address - State:CT
Practice Address - Zip Code:06419-9999
Practice Address - Country:US
Practice Address - Phone:860-663-3634
Practice Address - Fax:860-663-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE54153416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT699842OtherCONNECTICARE
CT590014003OtherRAILROAD MEDICARE
CT004010492Medicaid
CT710C070A2CT01OtherANTHEM BLUE CROSS
CTCT2195OtherHEALTHNET
CT590014003OtherRAILROAD MEDICARE