Provider Demographics
NPI:1245456813
Name:FOBARE'S AMBULETTE SERVICE
Entity type:Organization
Organization Name:FOBARE'S AMBULETTE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOBARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-529-6072
Mailing Address - Street 1:PO BOX 322
Mailing Address - Street 2:865 ST. RT. 95
Mailing Address - City:MOIRA
Mailing Address - State:NY
Mailing Address - Zip Code:12957-0322
Mailing Address - Country:US
Mailing Address - Phone:518-529-6072
Mailing Address - Fax:518-529-7338
Practice Address - Street 1:865 STATE ROUTE 95
Practice Address - Street 2:
Practice Address - City:MOIRA
Practice Address - State:NY
Practice Address - Zip Code:12957-0322
Practice Address - Country:US
Practice Address - Phone:518-529-6072
Practice Address - Fax:518-529-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30331343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01181295Medicaid