Organization
LIFESTAR LLC
Active
Other names
Canyon State Ambulance
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RALPH J VASSALLO JR. (VICE PRESIDENT OF BILLING SERVICES)
(602) 437-6620
Entity
Organization
Contact information
Practice address
1014 S WESTERLY, PAYSON, AZ 85541
(928) 474-2831
(928) 474-6188
Mailing address
PO BOX 63068, PHOENIX, AZ 85082-3068
(602) 437-1431
(602) 437-8436
Taxonomy
Speciality
Code
Description
License number
State
341600000X
Ambulance
Primary
58
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
590015162
RR MEDICARE
AZ
05
—
620949
—
AZ
01
—
AZ0152310
BCBS
AZ
Enumeration date
12/28/2005
Last updated
11/03/2009
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