Provider Demographics
NPI:1750379293
Name:ROY B PETTENGILL AMB ASSOC
Entity type:Organization
Organization Name:ROY B PETTENGILL AMB ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:TARKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-402-5899
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:CT
Mailing Address - Zip Code:06447-0308
Mailing Address - Country:US
Mailing Address - Phone:860-402-5899
Mailing Address - Fax:860-721-6362
Practice Address - Street 1:10 HEBRON AVE
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:CT
Practice Address - Zip Code:06447-1201
Practice Address - Country:US
Practice Address - Phone:860-295-6219
Practice Address - Fax:860-295-0604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC079B13416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004224565Medicaid