MEDICARE: FAB 5 TAXI LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)	M333176220109	MN

General Provider Information

NPI Number	:	1174070411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAB 5 TAXI LLC

Provider Business Mailing Address
First Line	:	712 40TH AVE N
Second Line	:	AVE NORTH
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55412-1706
Country	:	US
Telephone Number	:	612-298-5324
Fax Number	:

Provider Business Practice Location Address
First Line	:	712 40TH AVE N
Second Line	:	AVE NORTH
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55412-1706
Country	:	US
Telephone Number	:	612-298-5324
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DRIVER
Name	:	CHARLES LEE STEWART
Credential	:
Telephone Number	:	612-298-5324

Provider Enumeration Date	:	09/03/2016
Last Update Date	:	09/03/2016

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